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International S^xhibition of 1876, 



TYPHO-MALARIAL FEVER: 



Is IT A Special Type of Fever ? 



S^en^ai^lvS^ Ir|ti^odudtoi'y to tl\e f)i^du^^^ioi| of tl)e Question 



Section ofMedicine, International Medical Congress. 



BY 

J. J. WO O DWARD, 

Assistant Surgeon, U. S. A., 
IN CHARGE OF THE EErRERENTATION OF THE MEDICAL DEPARTMENT, IT. S. A. 



f>h iladelphia, 1876. 



J- * 



International 3i^xhiibition of 1876. 



TYPIiO-MALARIAL FEVER: 



Is IT A Special Type of Fever? 



'l\eii]cii%s^ Ii^ti'oduc^toi'y to tl|e Di^^t^ii^^^^s^ioi] of tl)c Que^s^tioi| 

IN THE 

Section of Medicine, International Mical Congress, 

—4 — 

J. jT WOODAVAKD, 

Ass/s^iiui SurgecDi, U. S. A., 
IN CHAKG15 OF THE KEPKESENTATION OE THE MEDICAL DErAIiTMENT, U. S. A. 




iladelphia, 1876. 



K<rri(KltH, rui.NTKItS, 

hmtjton, I). <;. 



Typho-Malarial Fever: Is it a Special 
Type of Fever? 



Since the earliest times Pestilence has followed in the footsteps of 
War. It has been the consequence of Ignorance as much as of Neces- 
sity. Its causes are to be sought, not merely in fatigues, exposures, and 
privations necessarily incurred during the performance of heroic deeds; 
not merely m the morbific influences of strange climates ; not merely 
in the miseries of besieged places ; they are equally to be sought in the 
thousand preventable abnormal conditions to which armies are exposed 
when huddled together in ill-selected, over-crowded, and filthy camps, 
fed by ignorance or cupidity on scanty, improper, ill-cooked food, drink- 
ing water contaminated by human excretions, and breathing air poisoned 
by human effluvia. Hence arises a brood of camp diseases more de- 
structive than the improved small-arms or rifled cannon of any foe; 
which, on memorable occasions in times past, have annihilated whole 
armies, and yet more frequently decided the fate of campaigns in spite 
of the military genius of generals or the heroism of their followers. 

The humane spirit of modern civilization revolted at horrors which 
modern science has shown to be to a great extent preventable, has made 
of late years earnest efforts at prevention, and the intelligence of modern 
administration has perceived that the success of such efforts is an indis- 
pensable condition to success in w^ar. It is this double motive that has 
called into existence the Medical Staff, which has become of late years 
an essential component part of the army of every ci^dlized nation. The 
work to be done cannot be performed by a band of hired barber-sur- 
geons employed to bind up rudely the wounds received in battle ; it 
cannot be performed by the voluntary assistance of the crowd of edu- 
cated civil physicians who may be led by motives of humanity to the 
scene of suffering, after the mischief is done and pestilence has actually 
broken out ; for its efficient performance it requires the existence of a 
trained IMedical Staff. 

To possess the desired efficiency such a staff must be a component 
part of the army in time of peace. It must enjoy such rank and pay in 
its higher grades, and offer to its lower grades such prospects of rea- 



4 



soiiably rapid promotion as to secure the life-long services of the ablest 
medical men. These mnst devote themselves in times of peace to the 
stud}^ of the sanitar}'- conditions which affect the health of armies, and 
war must find them ready to point out with authority the precautions 
which cannot be neglected without peril. The demands of philanthropy, 
the impulses of humanity, are best fulfilled by such a staff when it 
best discharges its militarj^ dnty, which is to see to it that of a given 
number of soldiers on the rolls, the largest possible number shall always 
be ready for duty. 

This proper duty of the Medical Staff is as much a military duty as 
that of the artillery or the infautry. It is the business of these to maim 
and destroy till the strength of the enemy is so diminished that he can 
no longer resist: it is the business of those to aid in keeping 
the fighting ranks full until their work is done. For the efficient dis- 
charge of this military duty the medical staff requires military rank as 
much as any other branch of the army service. It requires it, not 
merely because it is otherwise impossible to secure the continuous 
ser^dce of an efficient personnel, but because, without military rank, no 
personnel, whatever its qualifications, can be really efficient. It requires 
rank, because it requires authority. If its wise counsels can be thwarted 
at every step hj the obstinacy of ignorance, it becomes a mere witness 
of evils which it is impotent to prevent. 

This is not the time or place to discuss the question as to whether 
the conditions just indicated as necessary to secure the most efficient 
medical staff possible have yet been completely fulfilled in any army. I 
must leave that question to the thoughtful consideration of my hearers 
of all countries. It is enough for my present purposes to point out that 
coincidentl}^ with the elevation of the medical staff' in modern times the 
camp diseases of modern wars have notably diminished in malignancy. 
We no longer hear of armies destroj^ed by pestilence within the first few 
weeks or months after taking the field. The old bubo -plague and 
spotted typhus no longer figure m the history of wars between civilized 
nations. 

I admit that much remains to be done by Preventive Military Medi- 
cine. I admit that much remains to be learned with regard to the 
causes of disease. But this is no reason why armies should not 
enjoy to the uttermost the knowledge we already possess. And it is 
after all but a partial application of this knowledge which has brought 
al)out tlie amelioration to which I have just referred. I think it is safe 
to jiffirm that no army ever yet took the field, even in the most modern 
times, that did not campaign in daily violation of well-established hygienic 
laws. And hence it will l)e found that if in any modern war the mortal- 



5 



ity from disease has been very small, it has been because the struggle 
has been very brief. We shall deceive ourselves if we overlook the ele- 
ment of time in the production of the diseases of modern armies. An 
army may very well escape with trifling mortality from an exposure of a 
few weeks or months to influences which would have proved fearfully 
destructive if continued for a year or longer. 

This was well illustrated by the experience of the Armies of the 
United States during the civil war by which this country v/as recently 
convulsed. Notwithstanding the want of discipline among the newly- 
levied troops ; notwithstanding the lack of experience in military medi- 
cine on the part of the newly-enrolled medical officers ; notwithstanding 
all the faults of administration and the necessity of reform, of which so 
much has been said in certain quarters, the mortality from disease did 
not exceed 2.2 deaths per 1,000 of strength monthly, during the first 
six months of the struggle* — a death rate which, if it had continued, 
would have represented an annual loss from disease of 26.4 per 1,000 of 
strength. But in point of fact a rapid increase in the mortality took 
place after the first of November, 1861. The deaths from disease during 
the year ending June 30, 1862, were at the rate of 49.3 per 1,000 of 
strength, and, in spite of increased discipline and increased experience, 
the reorganization of the Medical Staff, and other reforms, rose to 63.2 
per 1,000 of strength during the year ending June 30, 1863. During 
the year ending June 30, 1864, the improved discipline and sanitary 
management of the white troops were at length accompanied by a dimin- 
ished mortality, and the death-rate from disease fell to 48.2 per 1,000 of 
strength, or very nearly what it w^as during the firf^t fiscal year of the 
war. Subsequently, however, it rose again, in spite of every effort, and 
was 56.5 per 1,000 of strength during the year ending June 30, 1865. 
These figures, it must be remembered, refer only to the white troops, 
who constituted the bulk of oiu' forces. They include both the regular 
army and the volunteer troops. And I may remark that I have shown 
in the introduction to the first volume of the Medical History of the 
War,t after an analysis of the records of the Surgeon General's office, 
and a careful comparison with the records of the Adjutant General and 
the Quartermaster General, that the average annual mortality from 
disease among the white volunteers, during the four years of the strug- 
gle, must be fixed at 55 per 1,000 of mean strength, while it was only 
32 per 1,000 of strength for the small regular army dming the same 
period. 

* These figures and tliose in the following paragraplis are deduced from the Statistical Tables of the 
first Medical volume of the Medical and Surgical Uistiyyy <yf the War of the A',-/'<'///,)//, ( iS6i-'5. ) Wasli - 
ington, Government Printing Office, 1S70. 

t 0/>. cit., Introduction, ji. XLI. 



6 



But what shall I say of the mortality among the colored troops'? 
The statistical tables in the first volume of the Medical History show it 
to have been 211 per 1000 of mean strength during the year ending 
June 30, 1864, and 139.8 during the year ending June 30, 1865. Even 
if w^e extend the view to cover the whole period from the day the first 
volunteer colored regiment was mustered into service to the day the 
last was mustered out, a period of five years and four months, and dis- 
tribute the mortality over the whole term, it will be found, as I have 
shown in the Introduction to the first volume of the Medical History,* 
that it represents an average annual mortality from disease of 133 per 
1000 of mean strength — a proportion which it is impossible to consider 
without emotion. 

It is only just to express my conviction that a large part of this exces- 
sive mortality was due to circumstances from which the colored men 
suffered before they were enlisted, rather than to mismanagement or 
maltreatment afterwards. It must be remembered that a large part of 
these colored soldiers were fugitive slaves. They fled into our lines 
literally naked and starving. The diseases which destroyed them were 
to a great extent engendered by the miseries they had suffered before 
they found a refuge under our flag. 

In all — embracing in the count all arms and all colors, officers and 
men — the total mortality of the armies of the United States from disease 
during the war, (including the deaths during the year following, in 
which a large part of the mortality was from diseases contracted during 
the struggle,) may be fixed at a little over 200,000 men, while battle and 
wounds destroyed rather more than 100,000-1 This estimate of 200,000 
men dead of disease embraces, it must be remembered, not only about 
30,000 of the colored soldiers, upon whose mortality I have commented, 
but a nearly equal number of white soldiers, who died while prisoners 
of war in the hands of the enemy, under circumstances upon which I 
refrain from comment at this time, but for which the Medical Adminis- 
tration of the United States army can assuredly in nowise be held 
responsible. 

These circumstances no doubt increased the mortality of our armies 

* op cit., Introduction, p. XL. 

fin the liurr)iliu;tinn lo the first Medical volume of the Medical and Surgical History of the War, I 
have fully di .. u , -rl llw; v:iri(.us ollicinl records, and arrived (see p. XXXVl 1 I ; al the following results, 
which are prohaMy \ ery neai- llie ii iuii : 

Dc.-xths from battle, woiuids, and (,iln r vioh iu;e 9.3.9''^9 

iJoalhs from diieasc 186,216 

Deaths, the causes of which are not r(;C(nded 24,184 

On the reasonable supposition that those deaths in which the causes arc not recorded were dislrihuled 
between wounds and disease in the same proportion as llmse whose causes arc recn-ded, we shall arrive 
al the results expressed in the te,\t. 



7 



greatly beyond what it would otherwise have been. On the other hand, 
it must not be forgotten that discharges from the service for disability 
took place with a freedom — perhaps in strict justice I ought to say, 
with a recklessness — never before exhibited in any array. The total num- 
ber of soldiers thus discharged may be estimated as not far short of 
three hundred thousand.* No doubt very many of these men only 
went home to die. No doubt, also, many thousands of them, especially 
those suffering with lame backs and general debility, rheumatic pains, 
and cardiac palpitations, needed only a short sojourn in a northern cli- 
mate, with a generous diet, to have fitted them again for the field. I 
cannot dwell here on this shameful story. It is one of the scandals of 
the war. I have never been able to collect data to justify even an 
approximate estimate of the proportion of these men who died. I 
believe it to have been comparatively small. Removed from the theatre 
of war, returned to the healthier circumstances of their homes, I doubt 
not that a large proportion of these men recovered their health, and 
that thousands of them, induced by the large bounties which were 
offered for recruits, found their way again into the ranks. 

Certainly the statistics I have cited afford food for earnest thought. 
But if their study is to be profitable, it must be undertaken with a 
careful consideration of all the circumstances. Above all, when these 
figures are compared with the results of other wars, the element of 
time must be taken into account, or the gravest misunderstandings will 
arise. A striking illustration of this possibility has been brought to my 
notice. 

In an oration delivered on the 2d of August, 1874, on the anniversary 
of the Military Medical School of Berlin, t Professor Rudolph Virchow, 
one of the ablest medical thinkers in Europe, alluded to this enormous 
mortality from disease during our war, and contrasted it with the com- 
paratively small losses of the German army during the late war with 
France. After reciting the American figures, and, I may add, after 
speaking of the publications of the Surgeon General's office in language 
so complimentary that, as one of the officers concerned in their prepar- 
ation, my modesty will not allow me to repeat it, the distinguished 
orator continued as follows : " The German army had, during the last 
French war, out of a strength of 913,967 men, a total loss of 44,980. 
Of these, 17,572 fell before the enemy, 10,710 died later of their wounds, 
12,253 fell a sacrifice to disease and pestilence; certainly a very favor- 
able proportion. But we had before us the experiences of two recent 

See Introduction to the first Medical volume, just cited, p. XI -11. 
■f J)u' Fortscli-rittc dcr Kricgslu ilku iid,' , hesondcrs hn Gcbietc dcr Infcctionskraukhcitcn. Rode 
gehalten v.wx Feicr dcs Sii riun-;sUi,m s dcr inilitar-ar/.tiichen I'.ililungs-Anstalten, am 2, August, 1874, von 
R. ViRCMow. r.erlin, verlag von \. Hirsciuvald, 1874. 



8 



wars, which had been well discussed and taken advantage of, both sci- 
entificalty and administrative^. We possessed the inestimable experi- 
ence of the Americans, and, finally, we had German science."* 

Truly, I will not yield even to Yirchow himself in my appreciation of 
German science. I know well the debt of gratitude which modern 
medicine owes to German investigation. For myself, I have di'awn 
much of the knowledge I value most from German sources. I admire 
German science for its industr^^ which is without parallel : for its orig- 
inality, which has already pushed discovery so far; but most of all, for 
the truly catholic spirit which knows no nationality, and for the manly 
independence, which never hesitates to weigh authority by a comparison 
with the actual facts. 

Something of this spirit I have tried to catch, and I will not therefore 
allow myself to be misled as to the matter under discussion, even by the 
authority of Yirchow. I cannot avoid interpreting the facts otherwise 
than he has done, and I feel that I am but performing a necessary duty 
when, standing here before you to-day, I declare it to be my opinion 
that not even German science would have sufficed to save the German 
army from a greatly increased percentage of mortality if the war had 
lasted a few years instead of a few months. 

The figures given by Yirchow are from the official report of Dr. En- 
gel.f They represent a period of seven months. They must not be 
compared with the losses of our whole civil war, but with the losses of 
the fii'st seven months. Let us make the comparison. Yirchow's figures 
represent a mortality of 13.4 -|- per 1000 of strength for seven months, or 
l.O-f- per 1000 monthly. Now, I have already shown you that the mor- 
tahty from disease in our a^rmies during the first six months of the war 
averaged 2.2 per 1000 monthly. During the following month, viz., No- 
vember, 1861, the mortality increased very greatly, so that, indeed, al- 
most as many died during that month as dui'ing the whole six months 
preceding. Includmg these deaths, I find, on a discussion of the official 
data, that during the first seven months of the civil war, viz., from May 
1 to November 30, 1861, the mortalit}^ from disease was at the rate of 
18.8 per 1000 of strength, or 2.7 per 1000 monthly.J You see that the 



* op. cit., S 7. 

\ Zeitschri/t des Kdniglich Preussischen Statistischen Bureaiis. Rodegirt von dcssen Director Dr. 
Ernst Enc;kl. Zwolfter Jahrgang, 1872. Berlin, 1872, S, 293. 

JThcse ratios are deduced from the Statistical Tables' in the first Medical volume of the Medical and 
Surgical History quoted above. I may add here, that the total number of deaths from disease from the 
commencement of the war to November, 1861, recorded on the alphabetical registers of the Surgeon 
Gener.al's Office, is 3,206. There are also 160 deaths recorded during the same time, the causes of which 
arc not specified. If we suppose all of these to have been deaths from disease, the number will be 3,36'). 
f^f this numl)er 1,457 died during the month of Nf>venlber, viz: 1,413 of disease, and 44 of causes not 
specified. The absolute number is but a little more than one-fourth of the (ierman figures ; bul the 
nvcr.igf: str<_nglh of tin troop-, in service during the time referred to was also aboiU a foin-th of the 



9 



mortality of our army from disease, during equal times, was really but 
about one-third greater than that of the German army in the French 
war ; whereas, as Virchow presents the subject, it is made to appear 
more than fifteen times greater. 

Now, I am perfectly willing to admit that a part of the actual differ- 
ence in favor of the German army was really due to better discipline and 
a wiser application of Preventive Medicine. But I do not believe that 
this is the only reason for the difference. The raw levies of the North- 
ern States were sent at the very first to the South, and campaigned or 
lay in camp during the time in question in the miasmatic valleys of the 
Mississippi, the Ohio, and the Potomac, while the German army did its 
work on the comparatively salubrious plains of France. What would 
have happened had the scene been exchanged ? How much of the dif- 
ference was really due to the wisdom of man, how much to a more 
favorable climate, and the absence of the intense malarial poison to 
which all were exposed who bore our arms f 

This malarial influence, and the pathological processes to which it gives 
rise, demand the most careful study of those who would endeavor to com- 
prehend the problem of the health of armies in America. It is not merely 
manifested by the frequency of ordinary ague, of which very nearly a 
million cases* were officially reported in our armies during the war ; it 

German army, so that the ratios are as stated in the text. The comparatively small mortality at the 
commencement of our civil war is strikingly illustrated by the Medical History of the three-months' vol- 
unteers. It will be remembered that at the commencement of the struggle President Lincoln called out 
75,000 men to serve for three months. This call was issLied April 15, 1861. According to the records of 
the Adjutant General's Office the actual number of men -who were mustered into service on this call was 
91,816. Through the kindness of Assistant Adjutant General T. Vincent, I have ascertained from 
the death and disability records of the Adjutant General's Office that the actual mortality of these troops 
during their three-months' service was as follows : 

Deaths from battle, woimds, and other violence ." 221 

" from disease X51 

" from causes not recorded 231 

Total ; 603 

If all the deaths of which the causes were not recorded were from disease, the total number of deaths 
from disease would be 382, or 4.2 per loo^) of strength for the tlu-ee months. This would correspond to a 
mortality of 1.4 per 1000 montldy, or less than three-fourths of the monthly rate which I have shown in 
the text for the first six months of the war. 

■■■•The number of cases and deaths rep!>rted as due to Ague was as follows : 





White Tkooi's. 


COLOKEI) Tkoops. 


Cases. 


Deaths. 


Cases. 


Deaths. 




447.258 
375.17" 
41.2-23 
13.673 






58 
54 
15 
794 




4,-,- ; >',s.yy2 


Quartan 1 lUerniitlLiil Kexrr 


04 
3.37" 


3.>)23 
2.536 




Total 


877,324 


4.287 


121,496 


921 





'i'he grand total for both white and colored troops is 998,820 cases and 5,208 deaths. See the first volume 
the Medical Histcn-y, cited above. 



10 

colors and complicates other diseases to an extent which can hardly be 
credited by those who have not been eye-witnesses to its effects. Espe- 
cially does it demand the consideration of those who may attempt the 
study of the fatal continued fevers which have been, and will be, the 
scourge of the camps of every army that operates in the valley's of the 
Mississippi and its tributaries, or of the rivers that flow into the Gulf 
of Mexico, and into the Atlantic ocean south of the fortieth parallel. 

These camp fevers occupy a conspicuous place among the diseases 
which produced the mortality of our armies during the civil war. They 
caused more than one-fourth of all the deaths from disease. In fatality 
they proved second only to diarrhoea and dysentery. I suppose it is 
safe to estimate that diarrhoea and dysentery produced about 60,000 
deaths in the armies of the United States during the civil war, and 
camp fevers rather more than 50,000.* A right comprehension of these 
two groups of diseases must therefore be regarded as the most important 
task of Military Medicine in America. 

It is my purpose in the present discourse to discuss certain points 
connected with the pathology of these camp fevers, and especially the 
complication of the typhous process by the malarial influences to which 
I have just referred. 

Already in the fall and early winter of 1861 reports began to come in 
from various quarters that a new form of fever was prevailing in our 
camps. The great majority of our army surgeons at that time were 
fresh from civil life. Many of them had been engaged in extensive pri- 
vate practice. Almost all of them were well acquainted with ordinar}^ 
typhoid fever (enteric fever, typhus abdominalis) as it annually prevails 
in the Northern States, and it was precisely these men who first called 
attention to the fact that the fevers they were now called upon to com- 



* 44,558 (Icalhs from diarrh.ca and dysentery were reported during the war, out of 156,885 deaths from 
dise.isc, tlic i-au>cs of wliich were specified in tlie reports. Tf we supjiose these diseases to ha\ e caused 
the saiiiL- pr..].! -rtiou <<f tlio^e deatlis from diseases the causes ofwhich are ncH specified in llic iLii^^n-. w c 
shall ohi.ii;i the estimate of the te.\t. The cases and deaths of tlve several forms of camp fewas reported 
to the Surgeon General's Office were as follows : 



Typhus Fever 

Tyjihoirl Fever 

Coinnif)!! C')iuiniie(l Fever. 

Tyijlio-malarial Fever 

Keiniltent P'ever 



Total. 



Whitk Tkc 



Cases. 



2,501 
75,368 
1 1 ,898 
49,871 
286,49^ 

426,128 



Deaths. 



850 
27,056 
147 
4,059 
3,853 

35,965 



ClJLOKF.l) 'I'lU 



Cases . 



123 
4, "9 4 



7, 5 '-'9 
30,6-^5 



42,391 



108 
2,280 



,301 
,002 



4,691 



'I'his gives a total of 40,656 (leatl)s from these fevers out of 156,885 deaths from disease, the causes of 
which arc specified in the rej)orts. ( )ii the supposition just mentioned we obtain the estimate in the text. 



11 



bat differed in many important particulars from those to which they 
were accustomed at home. 

This circumstance was noticed in both the Western and the Eastern 
armies ; but, so far as I have been able to ascertain, official attention 
was first directed to it in the Army of the Potomac, then encamped just 
beyond the banks of the river in fi'ont of Washington. By an order 
from the Adjutant General's office, dated December 6, 1861, a Board of 
Medical Officers was convened for the purpose of \dsiting the camps of 
the Army of the Potomac, and inquiring into the nature of the prevail- 
ing fever, especially endeavoring to ascertain — to use the language of 
the order appointing the Board — " whether it is to be considered an 
intermittent or bilious remittent fever in its inception, assuming in its 
course a typhoidal type, or a typhoid fever primarily." This Board con- 
sisted of Sui'geon A. N. McLaren, U. S. A.; Brigade Surgeon G. H. 
Lyman, U. S. Volunteers, and Assistant Surgeon M. J. Asch, U. S. Army. 
It convened December 16th, at the quarters of Brigade Surgeon Lyman, 
who was chief medical officer of the division commanded by General 
Fitz John Porter ; and during its subsequent labors examined the hos- 
pitals of this and other divisions, and collected a great deal of valuable 
information, in writing, by means of written questions addressed to the 
brigade and regimental medical officers of parts of the army which its 
members were unable conveniently to visit. As might have been ex- 
pected, some diversity of opinion w^as expressed in the replies received. 
But in their general tenor the great majority of these replies confirmed 
the opinion formed by the members of the Board on the basis of their 
own personal observations. This opinion was, that while a certain 
number of cases of ordinary typhoid fever existed in the army, the 
large majority of the febrile cases were " bilious-remittent fevers, w^hich, 
not having been controlled in their primary stage, have assumed that 
adynamic type which is present in enteric fever."' 

In the following spring, after the Army of the Potomac commenced 
its Peninsular campaign, this mixed form of fever increased in frequency. 
It assumed formidable proportions during the siege of Yorktown, and 
reached its greatest intensity while the army lay encamped on the 
swampy borders of the Chickahominy. The hospitals of Washington 
and Alexandria, of Baltimore, Philadelphia, New York, and other North- 
ern cities, were crowded to overflowing with the sick. Among the 
attending physicians were some of the best instructed medical men of 
the Northern States. They have shown that they recognized that they 
had to deal with an unusual pathological complex, by perpetuating the 
name of Chickahominy fever, which appears so often in their reports. 

It was under these circumstances that I was ordered, early in the 



12 



summer of 1862, to serve on a Board of Medical Officers, wlio were 
directed to revise the form of sick report in use in the army. I was 
fresh from the Army of the Potomac, which I had accompanied from its 
camps before Washington, where I had spent the winter with it. I had 
Inin in camp at Yorktown, and followed the army up the Peninsula. I 
had formed the opinion that the prevailing fevers of the Army of the 
Potomac were hybrid forms, resulting from the combined influence of 
malarial poisoning and of the causes of typhoid fever. I believed that 
individual cases received their characters in accordance as the one or 
the other of these influences preponderated in the individual, and that 
very often the picture was still further complicated by the coexistence 
of a scorbutic taint. Full of these opinions, I proposed to the Board, 
as I had previously suggested to the Surgeon General, to designate the 
complex condition in question by the name typho-malarial fever, and I 
induced the Board to add this term to the list of diseases printed on 
the blank form for the monthly sick report. I often regret that I did 
not also urge upon the Board the preparation of a circular letter to 
accompany the new sick report, explaining why this term had been 
adopted, and calling for special reports with regard to the cases which 
it was intended to designate. As it was, the term went upon the sick 
report without any explanation or a word of comment. But even under 
these circumstances, 23,346 cases Avere x^eported as typho-malarial fever 
during the following year, showing how widely the opinions I had 
formed were shared by the medical officers of the army. 

In September, 1863, I published in Circular, No. 15, of the Surgeon 
General's Office,* a short statement with regard to the sickness and 
mortality of the army during the first year of the war, in which I stated 
the meaning I designed to attach to the term typho-malarial fever, and 
in November of the same year completed the publication of my Outlines 
of the Chief Camp Diseases of the United States Armies,! in which I 
presented my views at some length. I also gave a short account of the 
subject in Circular No. 6, Surgeon General's Office, 1865. J And now, 
after a careful study of all the pathological and documentary material 

* Circular No. Ij, .'^.v/. (,r//,'r,i/'s (V//,, , W .islim-tcn, J). Septembers, 1863. Sickness and 
Mortality of the Arm • ' ■ ! ir.i V.-ar .irili.; War. 'I'lic lan-n.i-r hsl-I in t1iis preliminary- report 

was as follows : "jVl''- ,^ ii l.iin amonnt ni" une(ini])lieaU-il enlrrir and rciiiillent le\ er eer- 

tainly did occur, espeei.i li \ .il llu i ..n, imaK emenl ,,]' war, I lie \ a',' in,i i> 'lil \ ei" lie - i amp fevers of (lie 
army were of a mixed character, cxlnliilini; and. mljU d < aba ie ph. wi".' n i , \ ,1 1 a aisl y ei aal lined w ilh I lie 

periodicity and other peculiarities of malarial disease, ami si ill fnii a^ 1 1 Id, id lis lia iiiahina in inci- 

pieut scurvy, which is the ordinary conoiHiiitanl of camp diet. 'JO i ndie j 1 1 ih, m In am- ili, wrm 
typho-malarial fever, which I had the honor to sugj^cst to the Depart meni la Jiui , 1 , . pi i n appm- 
priale, and, at the jjresent time, is coming into very general use." 

f J. J. Wooi)WAi<i>, Outlines 0/ the Chief Camp diseases 0/ the United States Annies, as o/isrr7ied 
ihiriiif^ the present Tvar. Philadelphia: J. I'. Lii)piiicott tS: Co., iSfij. iivo. pp. 364. 

I Circular No. b, Surf^eon General's OJ/ice, W.ishiiigion, November i, 1B65, ]). n><) rt set/. 



13 



accumulated during the war, I still hold substantially to the same views, 
and hope in the second volume of the Medical History of the War to 
present the facts upon which my opinion is based in such a manner as 
to command universal assent. In so doing, I shall, of course, present 
many additional matters of detail not contained in any of my former 
publications ; and also, I may frankly say, I shall correct some errors of 
detail, particularly with regard to the pathological anatomy of the intes- 
tines in these fevers, into which I fell during my earlier studies, and 
which w^ere incorporated in the account presented in my book on Camp 
Diseases. 

In the same connection I hope to present historical proof of a proposi- 
tion, which I do not hesitate even now to announce to you, that such 
hybrids between malarial fever and typhus, of one form or another, are 
no new thing in the history of armies. They were not first begotten on 
American soil. In fact, in every great army that ever yet campaigned 
for any length of time in a malarial region the prevalent form of fever 
has been a hybrid between malarial fever and some form of tyj^hus. By 
a malarial region I mean simply a region in wdiich ague and remittent 
fevers are the common endemic diseases. The causes of these fevers act 
always with peculiar intensity upon strangers ; and an invading army is 
therefore peculiarly prone to suffer from them. At the same time the 
uncleanliness and overcrowding of camps favor the spread of some form 
of typhus, Avhether originating de novo or introduced from without by 
contagion. In some cases it has been spotted typhus which has made 
its appearance ; in others it has been abdominal typhus, (typhoid fever;) 
and as the typhus poison has been of one or the other variety, and as 
the malarial influence has been more or less intense, the complex result 
has varied — at times the malarial phenomena, at times the typhous 
phenomena being the more prominent. The morbid conditions result- 
ing fi'om these twofold causes have usually also been still further 
modified by the existence of actual scurvy, or at least of a scorbutic 
taint, the result of an improper and often scanty supply of food. 

It would be impossible, in the time allotted to me, to re-examine to 
any great extent the history of armies from this point of view. I can 
only bring to your notice a few striking illustrations. First, let me re- 
call the pestilential fever which destroyed the French General Lautrec 
and the army of thirty thousand men with which he besieged Naples, in 
1528. Hecker* has analyzed the chronicles of the time with his usual 
eloquence, and has arrived at the conclusion that it was simply petechial 
typhus which raged in the French camp. After an examination of the 



J. F. C Hkcker. TJie Epidoitics of the JM'tddlc Ages. Traiisl. of Sydenham Soc, London, 1844, 



14 



authorities he cites, I cannot agree with this conchision. The siege be- 
gan May 1st. Ahnost the first act of the French General was to cut 
the aqueducts which suppHed the city with water. By this rash act 
the plains on which he was encamped, intensely malarial at the best, 
were converted into a vast series of bogs and stpcgnant pools, fi'om 
which the heat of the sun raised clouds of vapor, which hung around 
his camp like a pall. I must believe that Jovius* was right in attribut- 
ing the destruction of the French army chiefly to this act of madness. 
No contemporaneous physician has described the pestilence that fol- 
lowed, but the chroniclers of the siege have recorded symptoms which 
are incompatible with the theory of Hecker. Jovius tells us that many 
of the patients were affected with swellings of the belly and legs. They 
became so pale and death-like in their complexions that their friends 
were hardly able to recognize them. Scarcely able to crawl, and with- 
out attendants to nurse them, they often died in their tents of hunger 
and thirst. Sandoval j describes the same death-like faces, and applies 
to them the epithet cmiarillos (yellow.) These are not the symptoms of 
spotted typhus, but of intense malarial poisoning. We .saw just such 
cadaverous yellow faces, with swelled legs and bloated bellies, crawling 
about in the camps at Young's Point on the Mississippi, and at other 
swamp-beset localities, during our own war. 

I agree, however, with Hecker, to whose work I must refer you for 
particulars, that spotted typhus was no doubt also present in the camp ; 
and I suppose it complicated the acute fevers very much, as it did later 
in the same century in the Austrian armies in Hungary. Moreover, 
Guicciardini J relates that after Lautrec first fell sick, during the month 
of July, things fell into confusion, the enemy cut off the convoys of pro- 
visions, and some of the soldiers actually died of starvation in conse- 
quence. These circumstances, I doubt not, also played their part in 
destroying the French Army. By the second of August there were but 
four thousand men fit for duty. Lautrec died August 15tli, and, the 
mortality still continuing, his successor thought only of flight. This he 
attempted August 29th, but was pursued, and capitulated at Averse a 
few days later. Crowded into the stables of la Madeleine, the pestilence 
continued its ravages among the prisoners, and when, a little later, they 
were released by the conqueror, but a handful remained to find their 
way back to France. 

* Jovii (Paui.i, Novocomensis, Episcopi Nuccrini) Ilistoriariun sui 'I'ciitporis. Tome ii, Florence, 
1550-2, Lib. XXVI. I have not obtained access to the original, bul Ihul in the Congressional Library a 
German translation, printed at Frankfort, 1570, 

t Sanijovai,. Historia dc la vida y hechos del Kji/pcnidor Cm los K Pamplona, 1614-18. Part II, 
Lib. XVII, XI, p. 12 et scq. 

JGuicciAKOiNi. Delia Istoria d' Italia. Lilj. X X, Venice, 1 738. I have used the English translation 
of A. P. Goddard, 3d Edit., London, 1763. 



15 



Next let me ask your attention to the story of the celebrated Hunga- 
rian fever, which for at least three centuries played so formidable a part 
in the campaigns undertaken by the House of Austria against the 
Turks. The valleys of the Danube and its tributaries are still the home 
of agues, remittent and continued malarial fevers, big spleens, and ma- 
larial cachexias. Lying further to the north than our own Mississij^pi 
valley, the climate is nevertheless such that the marshy borders of the 
streams and pools give rise to a malaria scarcely less intense than that 
with which we are familiar in the lower Mississippi. I may refer you 
to the papers of Mtillep:, Wenmaring, and Lantz* for graphic descrip- 
tions of the characteristics of the country and of its prevailing diseases 
in our own day. 

Now, in every considerable campaign against the Turks, in which the 
armies of the German Emperors invaded the Hungarian plains, from the 
beginning of the sixteenth century to the end of the eighteenth, a form 
of fever prevailed among the troops so unlike the ordinary European 
fevers that it has always been known as the Hungarian fever, and so 
fatal as to occasion the proverb that " Hungary is the grave of the Ger- 
mans." This Hungarian fever has exercised some of the best medical 
minds of the last three centuries. It is now generally admitted to have 
been a hybrid between the endemic remittent fevers of the Hungarian 
soil and spotted typhus. The attention of civilized Europe was first 
directed to it when, after the luckless Hungarian campaign of Maximil- 
ian II, in 1566, his pest-stricken soldiers returned to their homes. 
They scattered the contagion of spotted typhus throughout Germany 
on their way. The disease bred by that contagion was also called the 
Hungarian fever, but it was simply spotted typhus, and the student of 
the voluminous older literature of the Hungarian fever finds no little 
confusion growing out of this circumstance, and no little difference be- 
tween the descriptions of such eye-witnesses as Thomas Jordan and 
Tobias Cober, who described the Hungarian fever as they saw it on 
Hungarian soil, and the descriptions of those who merely observed the 
spread of spotted typhus in the German towns, and gave it the name of 
the Hungarian fever because the contagion had been spread by soldiers 
returning from Hungary. 

The army of Maximilian, however, was not the first German army 

* Jos. MijLLEK. Die k. k. Militao-gracnzc , viit besonderer Berucksichtigung der vereinigten Carl- 
stadter, Banal tmd VVarasdiiicr Graeii/.c. Mod. Jahrb. des k. k. oest. Staates. Bd 35, (1843,) S. 89, 
231, 361. Bd. 36, (1843,) S. no, 235, 338. F. Lantz. Phys. Med. Bcschreil>ii/i^- der Barafigaer Ges- 
paiinschaft in Ungarn. (Same Journal.) Bd. 55, (1846,) S. 98,231, 361. ])d. 56, (iS.|6,)-S. 99, 221, 349. 
B. Wenmaring. Ucber die Sumpfwcchsclficbr r . (Same Journal.) IJil. 57, (18 (6, ) S. 1 1 , 129. Consult, 
also, J. M. MiNDEREK. Ihis I [albdrcitagigd J'/rlu' >■ , ( Hcniitril;uus,) in den Sudliclu-it Provinzen des 
Rtissischen Reichs. Hufcland's Journal, l'>d. 28, si. 2, (1809,) S. 1. MUllek, cited above, speaks of this 
fever as the HeiJiitrita-iis Dacia-. Op. cit., Bd. 36, S. 343. 



16 



which had suffered fi'om the Hungarian fever. In 1542 a pestilential 
fever broke out at the camp before Ofen. in the Imperial German army 
which Margraf Joachim von Brandenburg had led against the Turks. 
It became still more fatal during the disastrous retreat, and according 
to Hteser* destroyed 30.000 men. Johannes Langius,! who accom- 
panied the Count Palatine, Frederick II, in this campaign, as well as in 
the campaign of 1526.J has left an epistle, in which he describes this 
fever in such a manner as to leave no reasonable doubt of its identity. 
He tells us, also, that the camp surgeons, whose ignorance he pictures 
with bitter sarcasm, gave the disease the name of Bhreiine (Braune) on 
account of the condition of the tongue, which they supposed to be the 
most essential symptom. According to H£eser,§ the Chronicler Wintzen- 
berger gave the same epidemic the name, "pestartige Braune." These 
names long continued in use among the designations by which the 
Hung'arian fever was known to the vulgar. 

The epidemic of 1566 is famous both on account of the manner in 
which tyx^hus was spread through Europe by the disbanded soldiers, and 
on account of the classical description of the Hungarian fever by Thomas 
Jordan,|| who accompanied the army of Maximilian as his chief medical 
officer. The spring had been exceedingly wet, and the great Hungarian 
streams had overflowed theii' banks ; the summer was unusually hot and 
dry; the German army was scantily supplied with food. When the 
fever first appeared the army was encamped at Komorn, at the point of 
junction of the "Waag and the Danube — a marshy, intensely malarial 
plain. It became still more destructive in the camp at Raab, where the 
Eaab and Eabnitz empty into the Danube. Such was the devastation 
caused by it that Maximilian, though hig" force when he went into camp 
at Eaab was about 80,000 men, did not venture to take the 'offensive, 
and saw the gallant little garrison at Zigeth captured by the Turks after 
more than twenty vain assaults, without daring to strike a blow in their 
behalf. In the early autumn he ignominiously retreated with the re- 
mains of his army. After the retreat the pestilence was especially 
destructive at Vienna. The hospitals could not accommodate all the 
sick, and the dead and dying were scattered through the streets. 
Throughout all this devastation it was the German troops that suffered ; 
the native Hungarians almost entu'ely escaped. 

* H.«SBR. Geschichte der epidemischen Krankheiten. 2te Aufl. Jena, 1865, Bd. II, S. 340. 

fl>. Johannes Langius. Med. Epist. Basel, 1554. Epist. 4, (p. 17.) In Cura Causonis Chir- 
urgicorum tevieritas. 

JSccHeckbr. An. Hungarica febris. In the Kncycl. Woerterbuch der Med. Wiss. Berlin, 1838, 
Bd. XVII, S. 164; with which compare the Dissertation by G. Agats. Dc Morl>. JIungarico. Berlin, 
1840. 

>/_ 0/>. cit., p. 341. 

! ThoM/K JoRDANi. J'cstis Fhcno!nc7ta. Franckfort, 1576. Cap. XIX, (p. 219.) Dc Luc Pannoiiia. 



11 

The Hungarian fever broke out anew during the siege of Papa, in the 
year 1597. The Itahan aUies suffered most. According to Hyeser, of 
more than 8000 of these troops, less than 1500 found their way back to 
Italy. This is the epidemic described in the admirable work of Tobias 
Cober.* 

Again it made its appearance, as we learn from Esslinger and Hseser, 
among the 12,000 German troops who occupied Hungary under the 
celebrated General Montecucuh,t in the year 1661. The disease broke 
out in the swampy camp between Komorn and Neuhausel, and soon 
brought the fi'uitless campaign to an end. 

Once more it appeared in the army with which Prince Eugene besieged 
Belgrade in 1717. The Grand Yizier advanced to the relief of the be- 
sieged with a great army. The Turks took the offensive, and shut up 
Eugene, mth his army of 60,000 men, in the marshy plain between the 
Danube and the Save. It was here that the Hungarian fever broke 
out, accompanied by a fatal dysentery. A large number of men had 
perished, when the gallant Prince, ventuiing all on the fortunes of a 
day, attacked the Turkish army and routed it after a desperate battle. 
The suiTender of Belgrade followed, and the peace of Passarovitz was 
the result. 

Still more terrible were the ravages of the Hungarian fever during 
the disastrous campaign which the Emperor Joseph II undertook 
against the Turks in 1788. Disappointed with regard to the help he 
had anticipated from Kussia, and his troops decimated by pestilence, 
the feeble campaign terminated in a humiliating retreat. The imperial 
army at the commencement of the season numbered about 200,000 
men ; its losses from disease have been estimated at between 30,000 
and 40,000. 

The symptoms of the Hungarian fever have been described at great 
length by numerous writers. I can only refer to a few leading points. 
The patients were seized, usually during the afternoon or evening, with 
a slight, short chill, followed by a burning fever. This was accompanied 
by a headache so intense that the vulgar called the disease sometimes 
the head disease, (Haupt-krankheit ;) the raging brain disease, (Hii'nto- 
bende-krankheit ;) or the head-misery, (Kopfwehe.) So prominent was 
this symptom that in the earlier autopsies medical men sought for the 
cause of the affection chiefly in the encephalon, and, deceived either by 
the congested appearance of the choroid plexus, or by the presence of 
vermiform clots of blood or fibrin in the ventricles or in the great 

* ToBL-E CoBERi. Ods . Med. Castrensium Hungaricarum. Decades tres. (Edition of W. Mci- 
bomius.) Helmstad, 1683. 

Memoir es de Montcciiciili. Nouv. ed. Amsterdam and Lcipsic, 1756. Lib. Ill, ch. 1, p. 321 . 



18 



sinuses, actually supi)osod they liad discovered worms in the brain, and 
gave to the disease the designation "Cerebri vermis" or "Hirn wurm." 
With the headache came on a pain in the epigastrium so intense that the 
appellations " Herzbriiune " and " Herzbreun," were widely employed. 
Soon the fever was accompanied by a raging delirium ; the tongue be- 
came dr}^ and covered with a brown coat, from whence the vulgar names 
" Braline" and " Pestartige Briiune," already nientioned. Hsemorrliages 
from the cracked tongue or from the gums were common. Then, there 
was also the characteristic typhus eruption of the skin, accompanied 
by petechipe, whence the disease was called "Febris Lenticularis," espe- 
cially by the Italian physicians. In cases which recovered, the favorable 
crisis usually occurred on the fourteenth or twenty-first day, but fatal 
cases often terminated much earlier. In some cases gangrene of the 
extremities occurred. 

All these symptoms, together with the unmistakable contagion, cer- 
tainly point to spotted typhus ; but from a very early period, cultivated 
phj^sicians, like Sennertus, for example, have pointed out that this fever 
differed in several marked particulars from ordinary spotted typhus. 
The most striking differences were its tendency to present a decidedly 
remittent type in its earlier stages, and the accompanying gastric symp- 
toms, bilious vomiting and the like. Even Rulandus,* who was disposed 
to identify the disease with the febris lenticularis of the Italians, was 
obliged to admit that during its early days it frequently presented, in a 
decided manner, the type of a simple or double tertian fever, A com- 
mon form was the semi-tertian, to Avhich the old Greek physicians gave 
the designation Hemitritseus ; and hence the Hungarian fever has 
sometimes been described as the Hemitritaeus Daci^e. 

So marked were these symptoms that Sauvages,t the great Nosologist, 
classes the "Amphimerina Hungarica," as he calls it, among the remit- 
tent fevers. The learned Naumann J goes so far as to declare that the 
Hungarian fever is at the bottom merely the common summer fever 
which occurs every year in Hungary, the valley of the Danube, and 
Southern Russia, and attains malignity only in epidemic years, ximong 
modern epidemiologists, while Ozanam § still clings to the notion that 



* Martin Rulanuus. De Morbo Un^^a^-ico. I-eipsic, 1610. Consult Cap. I, ]).(;, wlicrc, after inti- 
mating that these remissions are deer) ii i \ in tin ir rliaractcr, i laKa sp, l ic,) tin; antliDi- admits that in tlic 
case of IJaron Reinhard, who died . ' ' m I I : i m • m i.i n f. \ rr, lu- Nn|i|i' i . d . diirin;; \ \\' - ■ :i rlirr lnst(>i-\ of ilic 
case, that he was dealing merely wiili .1 dMul,!, 1^ ii;,,n. I', .i- hi. ,ir-iiniri,t in i.uui- of ilic idcniity of the 
Hungarian fever with febris lenticularis, see C.i p. \' II I , \\, p. ;76. Considt fuiilicr, Cap. Vlll, 
(luaiistio 39, p. 510, for argument against the sup)).., lii,, 11 ill. ii iln- I! iiii:j,,uian fever has truly a tertian or 
(luarlan type. 

fK. HoissiKK I)r SAi;vAf;ns. Nosologia Metliodka. Amsterdam, 1768, Tom. I, p. 327. 
X MoKirz Kknst Adoli-h Naumann. J lantilntch der Med. Klinik. Jid. Ill, Alnh. i, (lierliii, 1831,) 
S. 233. 

i;()/..\NAM. Hiy.t. Mi'd. dr.s j\Ial,i,{ii-s /■'./'id.'iiinjiirx. 2me. Edit., Paris, 1B35, Tome 111, p. 127. 



19 



Hungarian fever was merely typhus, botli Hecker and Hteser* express 
the opinion that it was typhus, modified by the intense malaria of the 
Hungarian plains. 

Side by side with the Hungarian fever a chronic affection occurred 
among the German soldiers in Hungary, which, like the Hungarian fever, 
was often spoken of as the Hungarian disease. (Morbus Hungaricus, or 
Liies Pannpnica.) This was the celebrated Languor Pannonicus, or 
Asthenia Pannonica.t It was a profound debility, accompanied with a 
disgust for food, unwillingness for exertion, diarrhoea, and pains in the 
back. It attacked large numbers of men, and not unfrequently proved 

•fatal. I suppose it to have been the joint effect of chronic malarial 
poisoning and a scorbutic taint. Much in the old descriptions reminds 
me of a certain group of cases of general debility which were common 
enough in our own war. These, too, were rebellious to treatment so 

.long as the j^atient remained in the malarial region, but recovered 
promptly, like some of the cases of Languor Pannonicus described by 
Tobias Cober, so soon as the patients escaped to a healthier atmosphere 
and better diet. 

Dysentery was another camp disorder which proved fatal in the Hun- 
garian campaigns. It is mentioned by various writers, as for example, 
by Cober, but does not appear to have attracted as much attention as it 
probably deserved. 

I cannot dwell further in this discourse on the story of the Hungarian 
camp diseases. I have said enough to indicate that the chief difference 
between these diseases and those of our own camps during the war of 
1861-'5 consisted in the prevalence of spotted typhus in Hungary in- 
stead of abdominal typhus, which was the form from which our armies 
suffered. The degree of malarial complication must have been very 
similar. The extent to which any scorbutic complication existed is 
difficult now to ascertain. Almost all the writers complain of the food 
and cooking of the Hungarian camps ; but the soldiers would appear to 
have had fresh meat in some abundance, for one of the constant com- 
plaints is that they persisted in cookiug it too soon after killing. Scurvy, 
of a marked kind, however, does not appear to have occurred, and the 
most significant evidence of the frequent existence of a scorbutic taint 
is, after all, the constant development in every army, after a few months' 
campaigning, of numerous cases of the Languor Pannonicus. 

Of late years we have heard but little of this once dreaded scourge, . 
which only now and then attracts the attention of some medical writer 



* Cited nliovc. 

f Fcr a tlcsi ripiion of tin- lanmioi- pannmiiciis, sec particularly llio work of Coi'.ek, cited above. Con- 
sull, also, SArvA<,i(s, op., it., 'I\.in. 1, p. 802. 



20 



whose tastes incline to historical studies. I cannot but believe, how- 
ever, that whenever a German army goes again into the valley of the 
Danube, as perhaps may happen before long unless the present disturb- 
ances in the Danubian provinces are fortunately brought to a peaceful 
termination, the old Hungarian plagues will once more appear in its 
ranks — a more formidable foe to be encountered than the sword of the 
Turk. 

I have thus presented to you a couple of striking illustrations of the 
hybrid disease resulting fi'om the complication of malarial influences 
with the causes of spotted typhus. Let me next refer to some examples 
of the similar complication with typhoid fever. 

The first instance to which I shall refer is the epidemic of the so- 
called morbus mucosus, which occurred at Gottingen during the years 
17 60-61, and which has become famous, less on account of the extent 
of the mischief done than because of the admirable description which 
we owe to two teachers in the Medical department of the Gottingen 
University, Roderer and Wagler.* The summer of 1760 was warm and 
rainy ; the winter which followed was wet, with notable vicissitudes of 
cold and mild weather. Besides the inhabitants, a garrison of French 
troops, numbering, with the camp followers, about 8,000, was shut up 
in the town. Roderer and Wagler have drawn a striking picture of the 
want of food, the uncleanliness, the general misery that prevailed. Al- 
ready by the middle of July, 1760, intermittent fevers, sometimes of 
mild type, sometimes, however, of marked malignity, occurred to a 
degree unusual in that region. During August the intermittents con- 
tinued to be prevalent, but malignant forms became more numerous, 
and many of the cases assumed a continued type. At the same time a 
malignant dysentery made its appearance, and raged with fatal results 
till the month of November. The intermittents meanwhile had con- 
tinued, but during the month of November both these and the dysen- 
teries were gradually replaced by the morbus mucosus, which became 
the prevailing disease, and continued as an epidemic all winter. During 
April and May, 1761, it was again, to a great extent, replaced by inter- 
mittents, but still scattered cases continued to occur during the sum- 
mer. In the autumn, intermittents again became the common disease, 
occuiTing often in a malignant form ; and small-pox, which had first ap- 
peared during the summer of 1761, assumed epidemic proportions 
during the winter of 1761-'2. 

The mucous fever was a continued fever, which in severe cases was 
often prolonged beyond the twenty-first day, sometimes till after the 
— — . — • — ■ 

* J. 1). KoUHKiiR L-l C. G. Wac;lei<. J)c' Morbo Mucosa. Gottingen, 1762. 



21 



thirtietli, though fatal cases often perished as early as the ninth. In 
its earlier stages it usually presented a decidedly remittent ty^De, tertiau, 
double tertian, or semi-tertian being the most common vaiieties. Some- 
times, as the patients convalesced, the continued fever passed into an 
ordinary intemiittent before recovery took place. After the fever was 
faii'ly under way it presented many of the symptoms of ordinaiy typhoid 
fever. Delii'ium, frequent, feeble pulse, diarrhoea, meteorism, in the 
worst cases petechife, made theu' appearance. At the beginning the 
tongue was furred, and its swollen, red papillae projected thi'ough the 
fur ; it became brown and dry as the disease progressed. H?emoiThages 
from the nostrils sometimes took place, esj^ecially about the sixth day ; 
still more frequent were haemorrhages fi'om the bowels. It is a sig-nifi- 
cant fact that the extract of Peruvian bark often proved highly efficacious 
in those cases in which the remissions were most marked. 

The disease derived its designation from the belief that an excessive 
secretion of mucus from the alimentary canal was its most characteristic 
phenomenon. This was manifested by the fi'equency with which mucous 
vomiting, with or without bile, occurred at the inception of the cases, 
just as we know it does in ordinary remittent fever. The diarrhoea was 
interpreted as but another expression of the excessive mucous secretion, 
and the dead lumbricoid worms which were often noticed in the stools, 
or during the progi'ess of autopsies, were supposed to have been bred 
in consequence of the morbid excess of mucus in the alimentary canal. 
In the autopsies, the closed glands of the stomach and small intestines 
were usually found tumefied to a marked degree. This was erroneously 
supposed to be the consec[uence of an accumulation of the mucous se- 
cretion in theu' interior. Koderer and Wagler have published three 
remarkable copper etchings of the appearances they observed. The' 
lesions they have figau'ed are not those characteristic of tyx)hoid fever, 
but of ordinary intestinal cataiTh. In one of the autopsies (No. Y) they 
describe the agminated glands, near the ileo-caecal valve, as marked with 
black pigment, quite like the condition often observed in our own war, 
and described as --the shaven-beard appearance." The mesenteric 
glands were enlarged. The anatomical evidences of peritonitis were 
often present. Dysenteric sloughs frequently existed in the colon. 
Nowhere, however, do I find any description of the bulky tumefaction, 
ulceration, and sloughing of the glands of Peyer, which is characteristic 
of typhoid fever. Nevertheless, I am by no means sure that this essen- 
tial lesion did not exist in some of the cases at least. It must be re- 
membered that the typhoid lesion was not then known as we know it 
now. Perhaps some of the gangrenous spots, of smaller or greater 
size, which our authors describe as having been observed in the smrJl 



22 



intestines of some of tlieir cases, were really of this natui'e.* This ap- 
pears to me the more probable, because in the case of the very similar 
epidemic which Sarcouef observed in Naples in 1764, and which, in the 
cu'cnmstances under which it occurred, its course, symptoms, and the 
anatomical lesions observed after death, appears to have been identical 
with the morbus mucosus of Eoderer and Wagler, I read that these 
gangrenous spots were again observed in the alimentary canal of some 
cases, and that they occurred chiefl}^ in the small intestines. But even 
if this interpretation is correct — and I believe it is — I cannot think that 
the characteristic tj^phoid lesion was present in all the cases in which 
Eoderer and "Wagier made autopsies, or it surely would have received 
greater attention from those acute observers, and I must think that in 
a part, at least, of their cases, there was no other lesion of the small 
intestine than a smart intestinal catarrh. 

The doctrine of the mucous fever, as taught by Eoderer and Wagler, 
took firm root in the medical mind of Europe. It figures largely in 
many of the text-books of the first half of the present century, and you 
will even find the descriptions reproduced, without criticism, under the 
head of "Mucous or pituitous fever," in the admirable Dictionary of 
Copeland.? Some writers have expressed the opinion that this mucous 
disease was after all neither more nor less than ordinary typhoid fever. || 
I cannot agree with them. I see in the story, as told by the original 
observers, unquestionable marks of malarial complications : indeed, also 
of scorbutic complications. I do not marvel that the Gottingen ob- 
servers should have devoted sections of their work to the discussion of 
the relationship of the mucous disease with intermittent fever, and of 
its relationship with scurvy, and should have arrived at the conclusion, to 
use tlieir own striking language, that the epidemic which they observed 
was the corrupted and degenerate progeny of interuiittent fever. They 
thought they saw also a causal relationship between intermittent fever 
and dysentery, an opinion which I cannot discuss here, but which I 
must confess I share to a certain extent. No doubt, since their time, 
the term mucous fever has often enough been applied to simple typhoid 
fever, and although of late it has been banished fi'om the books, it still 
survives among certain practitioners who were educated thirty or fort}^ 



* op. cit., p. 162. 

t Michael Sakcone. Istoria ragionata deimali osservatiin Napoli, nel corso delV anno 1764. Na- 
y>les, 1764. There is a German translation by Fuesslin, Zurich, 1772, and a French translation l)y 
Ucllay, Lyons, 1804. Our library contains the German translation only. 

J OzANAM. op. cii., Tom I, p. 257 jt-i/., gives an excellent abstract of the works of Rcklcrcr and 
Wagler, and of Sarcone. 

^Jamks Coi'ELANn. Did. 0/ Pjact. Med., London, 1858, Vol. I, p. 988. 

II As for example, W. Gkiksi:nc;eu. Infections-KrankJicitcn . Virchow's Ilandlnicli dcrSiicc. Path. ti. 
'I'hcrapic. P.d, II, abth. 2. Eriangcn, 1857, S. 118. 



23 



years ago, and I m3^self have heard it apphed by old practitioners to un- 
mistakable cases of typhoid fever within the last five years. The misuse 
of terms in medicine is, however, a common consequence of imperfect 
Imowledge, and we must not allow ourselves to be led astray by it. 

I cannot dwell longer now upon this interesting epidemic. Let me 
turn next to another illustration, in which the malarial element was still 
more potent, and with regard to which I need only present a few salient 
points, because it is so often cited in connection with the diseases of 
armies that most of the leading facts must be well knovvTi to you all. I 
refer to the Walcheren fever, which decimated an English army in the 
year 1809. 

The previous experience of English armies in the Netherlands had 
shown the malignant character of the malarial influences which prevail 
in that region. It had been described in striking language in the excel- 
lent work of Sir John Pringle."^ He had recorded that all the flat region 
between the rivers Lys and Scheldt and the sea, was marshy and un- 
healthful, the home of periodical fevers ; that a great part of Holland, 
including Dutch Brabant, was subject to the same disorders, and that 
the air was worst of all in Zealand. He has left graphic descriptions of 
the fevers which prevailed among the English troops operating in these 
low countries between 1742 and 1748. He had observed especially that 
when the troops were encamped near stagnant waters the marsh fevers 
are not only apt to begin with little remission, but, after intermitting 
for some days, to change into continued fevers of a dangerous nature."! 
Especially was this the case during the summer and autumn of 1718, 
when the troops were encamped near the inundations of Dutch Brabant. 
An epidemic of such fevers occurred among them. Pringie writes : 
"At the height of the epidemic it appeared that both intermittents and 
remittents, by extending or doubling their paroxysms, frequently 
changed into a continued and dangerous form, and that most of those 
we lost died in this way. These men, as we remarked, had a corrupted 
smell for a day or two before their death, and soon after, their bodies 
putrefied. Some had petechial spots, though the place where they lay 
was neither crowded with sick nor too close ; and to these spots were 
added some other symptoms, the same with those of the hospital 
fevers, "i 

The expedition of 1809 renewed the experiences of Pringie on a more 
formidable scale. The English army, of between 42.000 and 48,000 
men, was quite health}^ when it set sail from the Downs, July 28th, but 

Sir John Pkincle. O/'s. on the Diseases of the Army. 7th Kilit., London, 1774, p. \,et scq. 
\0/>.cit.,^.i73. 
X O/'. cif.. p. 181. 



24 



as early as the middle of August the number of the sick was so great 
as to excite alarm. By the 26th the mimber was 5,000. By the 7th of 
September it amounted to 10,948. According to Sir Gilbert Blane,* 
26,846 men were sent to hospital in Zealand between the 21st of August 
and the 18th of November. The expedition was paralyzed by these 
misfortunes, and after the surrender of Flushing, August 15th, was 
unable to continue offensive operations. In spite of the fact that a large 
part of the sick who were sent home to England began to improve so 
soon as they escaped from the pestilential regions in which their diseases 
had originated, and ultimately recovered, the total mortality was large. 
It has been estimated at about 8,000 men. I must refer you to Han- 
sard's Parliamentary Debates, the Annual Kegister, the Edinburgh Ke- 
view, and the Essays of Marshall, Sir Gilbert Blane, Dawson, Davis, and 
Wright t for the particulars of this disastrous expedition. I can only 
pause to emphasize a few facts. 

The diseases of the Walcheren expedition were diarrhoea, dysentery, 
intermittents, and a form of fever which began as a remittent, and sub- 
sequently assumed a continued form, and which at that time was 
designated the Walcheren fever, or the Walcheren remittent. Sir Gil- 
bert Blane, who visited the island of Walcheren dui'ing September and 
October, reported to the Government " that he found so great a propor- 
tion of the sick to consist of those affected with the intermitting and re- 
mitting fevers peculiar to marshy countries, that there could be no doubt 
that the sickness of the army was owing to that cause." He admits, 
however, that he found a certain number of cases of a fever which he 
called " t;yTDhus," and of dysentery, particularly at Flushing, where " the 
prevalence of these two diseases was very remarkable, particularly in 
one regiment, of which all the medical officers were either absent or 
dead, and of which the sick, originally affected with the endemic disease, 
were suffering also from typhus and dysentery in consequence of the 
want of cleanliness, as well as of proper medicines, diet, and attendance. 
Borland and Lempnere,§ two other medical officers serving with the 



* Sir Gilbert Blane. Facts and Ohs. respecting Intermittent fevers, and the exhalations ivhicJi 
occasio7t them. Med. Chir. Trans. Vol. Ill, (1812,) p. 11. 

f Hansard's Parliamentary Debates. Series I, Vol. 15, Appendix 22 and 23, and Vol. 16, Appendix 
" Papers relating to the Expedition to the Scheldt." The Edinburgh Annual Register for 1809. Edin- 
burgh, 1811, Vol, II, part I, p. 660. Tlie New Annual Register for 1809. London, i8io, p. 316. Ob- 
servations on the documents , including the eiiidence heard at the bar, laid before Parliament on the 
subject of the late Expedition to the Scheldt. The Edinburgh Review, Vol. 17, (i8io-'ii,) p. 331. 
Henry Marshall, Cotitribntion to Statistics of the Sickness and Mortality which occurred ajnong the 
troops employed in the Expcilitin)! to the Scheldt i?i the year 1809. Edinburgh Med. and Surg. Jl. Vol. 
48, (1837,) p. 305. Sir GiLi!i:iM IJi.ane, op. cit. Davis, Wright, and Dawson — works cited below. 

X Op. cit., pp. 2 and 3. 

2 J. I'orland and W. Lemi-riere. Report on the prevailing Malady among his Majesty's P'orces 
scriiing in the Island of Walcheren. The Med. and i'iiysica! Journal, Vol. 23, (1810,) p. 183. 



25 



troops on the island, reported, in the same spirit, that the malady was 
" the endemic fever of marshy countries ; the effect of miasmata from a 
soil the most productive in deleterious exhalations of any perhaps in 
Europe;" stated that it prevailed also among the natives of the island 
as an intermittent or remittent fever, and that among the British troops 
it assmned "'a character of greater mahgnancy. " 

But the most elaborate studies of the AYalcheren fever were made by 
the medical men whose duty it became to treat the sick who were sent 
home to England. Dawson* tells us that the Walcheren soldiers were 
affected with intermittents in a number sui'passing those who were 
attacked by the continued fevers ; that many of the soldiers who were 
subjects of the continued fever had already labored under the intermit- 
tent, and that on the other hand intermittents we;re common among 
those who had recently recovered fi'om the continued fever. Davis.t 
whose account of the fever is more elaborate, tells us that at the begin- 
ning it assumed the quotidian, tei'tian, double tertian, or quartan ty^^e. 
but that the most common of all was the double tertian. It assumed, 
however, the characters of a continued fever of typhoid type as it 
progressed, with mutteiing delii'ium. small rapid pulse, diy. black 
tongue, sordes-covered teeth, foetid odor, and black discharges fi'om the 
bowels. 

On accoimt of the fi'equency with which this fever was associated 
with dysentery, the characteristic lesions of dysentery were frequently 
found in the colon during the autopsies which were made. But Davis i 
has also recorded the significant fact that ••the'ileum and jejunum were 
fi'equently interspersed with tubercles, inflamed and ulcerated in differ- 
ent pai'ts." This description would seem to indicate beyond doubt 
that the lesions, which we have now learned to recognize as character- 
istic of typhoid fever, were fi'equently present in the cadavers of 
those who had perished from the Walcheren disease. After a thought- 
ful study of the evidence, no doubt is left in my own mind that this 
fever was not, as has often been asserted, simply a mahgnant remittent, 
but that it was a genuine hybrid between malarial and enteric fever. ? 

Did time permit. I might bring forward other interesting illustrations 
from the history of the British Ai'my in the East and West Indies and 
elsewhere, from the Algerine experience of the French, and fi'om other 
soui'ces : but I fear that I have already occupied too much of yoiu' time 

*G. P. Dawson. Ol>s. on the IValcheren Diseases. London, 1810, p. 70. 

t J. B. Davis, A Scientific and Popular view 0/ the Fever 0/ Walcheren. London, i8io. See also 
Thomas Wright. History 0/ the Walcheren Remittent. London, i8ii. 
X Op. cit., p. 192. 

g Essentially the same opinion with regard to the W.ilcheren fever has been expressed by J. J. Levick. 
Miasmatic Typhoid Fever. American Jour, of the Med. Sciences, April, 1864, p. 409. 



26 



with facts of this class. I cannot, however, leave the subject of the 
experiences of other armies without bringing- to your notice an unex- 
pected corroboration of the views I am urging upon your attention, 
which I find in an essay published by Yirchow in 1871 on the fever and 
dysentery of the German army* during the recent war with Francp, 
which he contrasts mth the similar diseases of our own civil war. as 
described by me in my book on Camp Diseases, and in Circular No. 6. 
Yii'chow hesitates to acknowledge " typho-malarial fever" as a special 
group of diseases, and exclaims, with cautious conservatism : "It seems 
to me we ought to be very careful in this direction." Yet, in the same 
essay, while contending that the prevpJent fever of the German army 
was simply abdominal typhus, as proved by numerous ^>05^ mortem 
examinations made at Berlin on soldiers brought back sick from the 
front, this cautious but acute observer finds himself compelled by the 
facts under his eyes to use the following emphatic language : 

" Nevei-theless. abdominal typhus affords such numerous diversities in 
its course that it is in the highest degree imperative to preserve every 
precaution in the interpretation of individual cases. Especially does 
the admixture (Zumischung) of the malarial element, which also in this 
war has shown itself active, by numerous cases of intermittent fever, 
confuse the picture of the so-called normal course of typhus in a some- 
times very deceptive manner.'" 

Now, I must protest that these words represent the very essence of 
the doctrine I am here to defend, and if the comparatively mild malaria 
of the plains around Metz was capable of complicating the course of the 
abdominal typhus which occurred in the German army to a sufficient 
extent to justify this eloquent Ip.nguage, what think you would the 
great pathologist have written could he have observed for himself the 
fevers of our own arni}^ in the valley of the Mississippi or by the banks 
of the Chickahominy ? 

I have occupied the greater part of my hour with these preliminary 
matters : but not, let me hope, in vain. I come now to a rapid sketch 
of the principal facts with regard to the typho-malarial fever of the civil 
war of 1861-'5. 

The characters and distribution of the malarial fevers of the region in 
which that colossal struggle took place have been described m a most 
original and interesting work by our coimtryman, Dr. Daniel Drake,! 
who has embraced them under the general designation of autumnal 
fevers. This term serves very well to express the greater prevalence of 

* R. ViRCMow. Kriegstyphus unci Ruhr. Virchow's Archiv., IJd. LII, (1871,) S. i. Note, pp. 5 and 30. 

t Daniri. Drake. The Pri7icipal Diseases of the Interior Valley of North America. Cincinnati, 
1850. The same, j^cWj^rzVj, edited, after the death of the author, by S. H. Smith and Francis G. 
Smith. Philadelphia, 1854. 



27 



intermittents and remittents during the antnmn months ; but it must 
be distinctly understood that their occurrence is not limited to these 
months. In the regions in which they are endemic, the}^ may occur at 
any season of the jea,i\ and their course can be represented by a curve 
in which the abscissas begin to lengthen early in the spring, and grow 
longer and longer, till they attain their maximum most generally at 
sometime dming September or October, after which the curve rapidly 
drops to a minimum during the winter. Sometimes the cuiwe presents, 
also, a slightly irregular elevation during the early spring, justifying 
the term vernal intermittents, which has often been used; but most 
generally the increasing frequency of these fevers in the spring simply 
represents the commencement of the annual rise in the curve which 
culminates in the autumn. This is well illustrated by curves which I 
have had constructed to represent the monthly number of new cases of 
agues and remittents reported in our armies in the Atlantic and Central 
regions during the civil war. These I hand you for examination, but I 
cannot pause to discuss them at this time. Doubtless the winter and 
vernal cases are to be regarded in part as relapses, in part as illustra- 
tions of the postponed development of the consequences of previous 
exposure ; but, however you may choose to interpret them, I wish to 
insist upon the point that they occur with much greater frequency than 
some of the systematic wi'iters would have us believe. 

Dr. Drake has shown that in a general way these fevers are most in- 
tense in the States that border on the Gulf of Mexico, and gradually 
diminish in frequency and severity as we go to the north, so that they 
no longer prevail in epidemic form beyond the 44th parallel, and cease 
to occur even sporadically at about the 47th. To the southwest, the 
Cordilleras of Mexico and the Southern Rocky Mountains constitute 
their boundaries, while in the higher latitudes they cease on the great 
plains, long before we reach the mountains. On the Atlantic slope they 
prevail with constantly increasing severity as we go southward from 
New York, and though they do not occur on the table lands and higher 
ground of the Appalachian chain, yet they ascend high up the valleys of 
the streams which flow out of the flanks of those mountains. 

In the volume of the Ninth Census of the United States, which is 
devoted to Vital Statistics,* there is an interesting map which exhibits 
the distribution of the mortality from intermittent and remittent fevers 
during the year 1870. Doubtless this mortality, which is but at best 
incompletely represented in the Census Report, can only be regarded as 



■^^ Nintli Census, Vol.11, Vital Statistics oj the United States. Washington, 1872. See, also, .9/'rt/'/V- 
tical Atlas of the United States — based on the results of the Ninth Census, jS/O. I'y V. A. \\' \i i^ik , 
1874, in wliich the map in ([iiostion is given on :i larger scale, anil better engraved, as Plate 



28 



a very imperfect measure of the frequency and severity of these fevers ; 
but imperfect as it is, its indications are vahiable. It shows in a gen- 
eral way the almost complete exemption of New York, the New England 
States, and the mountainous parts of Pennsylvania, Maryland, AVest 
Virginia, and Virginia, and a gradual increase in severity indicated by 
an increasing mortality in the river valleys as w^e go southward from the 
fortieth parallel. It illustrates, also, in a striking manner, a fact which 
arrested the attention of Drake,* that in various scattered districts, from 
the influence evidently of strictly local causes, the malarial fevers display 
greater prevalence and malignancy than they exhibit further south and 
on a lower level. 

It would be altogether foreign to my purpose to enter in the present 
discourse into any discussion as to the causes of these fevers. I simply 
urge upon you to-day the great fact of their endemic existence, in some 
localities more frequently and with greater severity than in others, 
formidable even to the natives of the soil, but still more formidable to 
strangers, throughout the whole region in which our great armies oper- 
ated during the civil war. The characters of the fevers thus distributed 
are too well known to you all for any description to be necessary here. 
I need only remind you of the frequent occurrence throughout the 
Southern States, side by side with ordinary ague, of malignant forms, 
the so-called congestive chills or pernicious fever ; of the severity of the 
remittent fevers which prevail ; of the frequency of big spleens, disor- 
dered livers, and malarial anaemias, and of the great frequency with 
which, in these regions, an intermittent type is impressed on the ordi- 
nary acute phlegmasise, and even on chronic disorders. 

Drake has also presented an interesting account of the distribution 
throughout the United States of typhoid or, as he calls it, typhous 
fever. t This fever is the usual form in w^hich typhus manifests itself in 
the United States. The spotted typhus of the Old World never appears 
on our soil except as isolated cases, imported, as "ship fever," into our 
seaports. Drake has correctly pointed out that while in a general way 
the typhoid fever of the United States is more prevalent in the Northern 
than in the Southern States, it nevertheless does occur both sporadically 
and in local epidemics even in the southernmost portion of our territory. 
This fact is strikingly illustrated by a map in the volume of the Ninth 
Census already referred to, J which represents the distribution through- 
out the United States, during the year 1870, of some 24,000 deaths 
from typhoid fever. In constructing the map a few hundred cases of 

* Of>. cit., First series, p. 704. 

t 0/>. cit., S(;coiul Series, p. 358 ct .icq. 

X See also Walker's Statistical Atlas, cited al)ove, Plate 46. 



29 



cerebro spinal fever were included, but their number is too small to 
vitiate its value* in illustrating the distribution of tyi^hoid fever during 
the year in question. This map, while exhibiting in a general way a 
gradual decline in the mortality from typhoid fever as we go to the 
South, displays also a number of limited areas of high mortality, rep- 
resenting the endemic prevalence of the fever during that particular 
year in certain localities. Several of these areas of local prevalence are 
situated in the Southern States. In one of them, in Georgia, which 
embraces the region drained by the Altamaha and Satilla rivers, typhoid 
fever caused about one-fifth of all the deaths — a greater mortality than 
it produced in any part even of the New England States. In another 
almost equally remarkable area, embracing parts of the States of 
Mississippi and Alabama, having near its centre the town of Columbus, 
Mississippi, the proportionate mortality fi'om typhoid fever was nearly 
as great. 

Drake has urged, as one of the distinguishmg marks between tyj^hoid 
fever and the autumnal fevers, that the former is not limited like the lat- 
ter to a particular portion of the year, " between the summer and winter 
solstice, but occurs, though unequally, at every season." But he beheves 
that " on the whole, however, they are most prevalent in autumn and 
winter, "t an opinion which has been shared by several careful writers. J 

Liebermeister § has recently compared the statistics of the monthly 
prevalence of typhoid fever in some of the great Eui'opean cities, and 
shown that in London, Berlin, and Basle, the curve which represents the 
course of the disease is distinctly autumnal in character. " The mini- 
mum is in February and April, (in the Berlin curve a httle later;) the 
maximum is in September and October. (In Berlin, the maximum is in 
October.") Munich alone presented an exception, the maximum falling 
in February. Now, I must say, my study of the sick reports of our civil 
war inclines me to believe that the autumnal curve observed by Lieber- 
meister represents also the usual annual distribution in this coimtry. 
I have constructed curves representing the monthly ratio of new cases to 
strength in each of the three regions. These ciu'ves present certain ir- 
regularities in the Atlantic and Central regions corresponding to the 
varymg circumstances in the fortunes of the great armies, but on the 
whole they represent the disease as most prevalent during the latter 

* Ninth Census, Vol. II, cited above. Special tables of Mortality, p. XXIII. The number of cases is, 
enteric fever, 22,187; typhus fever, 1,770; cerebro-spinal fever, 650, The cases reported as typhus were 
simply misnamed, and are to be regarded as enteric. 

t C/. czt., 2d Series, p. 358. 

J See, for example, G. B. Wood. Treatise on the Practice of Medicine. 6th Kd., Philadelphia, 1S66, 
Vol. I, p. 383. 

g LiEBEKMEisTEK. TypJioid Fevcr , in Ziemssen's Cyclopaedia of the Practice of Medicine, Anier. 
transl., Vol. i. New York, 1874, p. 65. 



30 



part of tlie sniiinier and antuiiiii, ratlier than during the autumn and 
winter. In the Pacilie region the curve is strictly autumnal. The 
maxima are as follows : October in 1861, September in 1862, Novem- 
ber in 1863, September in 1864, October in 1865. The minima 
were in April and May for 1862 and 1863, April, 1864, and March, 
1865. In the Atlantic region the maximum for 1861 was in No- 
vember. In 1862 there were two maxima, one during the Penin- 
sular Campaign in July, followed by a great reduction on the with- 
drawal of that army, and a second maximum in October and No- 
vember. In 1863 and 1864, the maxima were during July and August. 
In 1865, during October. The minima fell in March, 1862; June, 
1863; February, 1864; and April, 1865. In the Central region the 
maximum for 1861 fell in November ; in 1862, in May. During 1862 the 
curve was quite irregular; it rose to a maximum in May, then dimin- 
ished in frequency during the summer, and steadily increased after Sep- 
tember through the winter, attaining its maximum in February, 1863, 
after which it diminished until June, and then again increased to a sec- 
ond maximum m August. The maximum for 1864 fell in September ; 
in 1865, during September and October. Th5 minima were in March 
and September, 1862, June, 1863, February in 1864 and 1865. 

I find from the Annual Keports of the Board of Health of the city of 
Boston, for 1874 and 1875, that the mortality from typhoid fever during 
those years pursued a markedly autumnal course, the maximum being 
during September in 1874, and during October in 1875.* In the District 
of Columbia the registration returns show that the greatest number of 
deaths since 1872 have always occurred during the months of August 
and September. 

I incline, therefore, to the belief that typhoid fever presents in fact 
in this country an annual autumnal curve very similar to that of the 
so-called autumnal fevers. I base upon this circumstance no argument 
as to the relationship or nature of either disease, but press it upon 
your attention [is a fact which must not be overlooked. 

Next, let me remind you of the important fact that intermittent and 
remittent fevers often disappear more or less completelj^ from neighbor- 
hoods in which they have long prevailed, and are replaced by typhoid 
fever. This circumstance could not cscajx' such a faithful observer as 
Drake. He has described it in the folio wiug language : 

" Far in the North, remittent fever often presents, almost from the 
beginning, a tendency to the continued type, displaying the character- 

"■'^f^K. Second Annual Report of the Board of Health of the City of Boston, 1874, and Tliird ditto, 
1875. 15otli volumes give charts representing the weekly mortality from typhoid fever. Also, Atinjuil 
Reports 0/ the Board 0/ Health 0/ the Dhtricl 0/ L'o/u)iil>ia for i8^-.', 1873, 1874, and 1875. 



31 



istics of the syiioclms of Cnllen's Nosology. It is properly called 
autumnal fever, l:>ecause it prevails most in that season, and is an 
equivalent for the true remittent fever of the warmer climates. Nearly 
the same remark is applicable to this fever when, in the middle latitudes, 
it appears in the long-cultivated and diier portions of Tennessee, Ken- 
tucky, western Pennsylvania, and Ohio. Formerly it often abated into 
an intermittent ; latterly, it is apt to degenerate into a continued type."* 

Whatever criticism you may choose to bestow on the wording of some 
parts of this remarkable passage, it is an honest attempt by a keen 
observer to describe a class of facts which he had had the opportunity 
of observing on a great scale. The substantial truth, that in numerous 
districts throughout this land intermittents and remittents were the 
prevailing form of fever when the first settlements were made ; that as 
time passed by and cultiva^tiou progressed, the intermittents diminished 
in frequency, the remittents exhibited more and more a disposition to 
pass into continued forms, and finally were replaced by ordinary t3q)hoid 
fever, which became the prevailing endemic fever — all this, I suppose, 
has occurred under the personal observation of many of the American 
physicians who listen to me to-day, and I need not weary you by multi- 
plying authorities in proof of a fact with which you must all be familiar. 

But next let me observe that the change thus effected is not always a 
permanent one. Often in individual years the intermittents and remit- 
tents reappear in epidemic-wise in regions such as I have just described, 
and then the typhoids vanish for a time, to return once more when the 
temporary prevalence of the periodical fevers comes to an end. 

Existing thus side by side, replacing each other in this intimate — if 
you will, in this intricate manner — it is evident that the unknown causes 
of the periodical fevers, and of typhoid fever, whatever they may be, 
must frequently coexist. Ought we not, then, to anticipate that indi- 
viduals exposed to both would often suffer with fevers in which phe- 
nomena belonging to both affections would also coexist ? 

I suppose the once popular belief that diseases are entities, and that 
a man can suffer from but one at a time, is now so completely dead that 
it is quite unnecessary for me to bring forward facts and argiiments to 
disprove it. I suppose it to be now well established that individual 
cases of disease are always more or less complex, representing in every 
instance the total effect of all the morbific causes acting upon the in- 
dividual, and modified always by his individual resisting power, the 
result of his own individual organization and his own previous histor3^ 
Even Sauvages, the greatest of all the systematic nosologists of the last 
century, already recognized this fundamental fact when he exclaimed, in 



* Drake. Op. cit. First Series, p. 781, 



32 



the introdaction to his woit : Grenera and species of diseases are ab- 
stract notions. Throughout the ITniverse neither genera nor species 
exist- bnt only indiTidnals."* Is it wonderful then, that hybrid forms 
of disease, exhibiting the ordinary symptoms of malarial and of typhoid 
fever. Tariously combined- should long haye been observed in this coun- 
try ? In feet, such hybrid forms have long been observed in Europe 
also. In the first vohime of his Institutes, published in 1781, Burserius j 
recognized iliem as a group : ** the Proportionata." which he defines as 
a compound species composed of the synochus and intermittent fever. 
This union, he says, occurs especially " when intermitting fevers prevail 
epidemically, or at least constitute the prevailing and stationary disease ; 
for then almost all diseases bear some resemblance to intermittents, or 
sporadic, or intercurrent fevers, of whatever other kind, are combined 
with tiie intermitting fevers." 

HCTmann Schmidt.! in his account of the so-called Summer fever, which 
was epidemic tiiroughout Europe during the year 1827. has still more 
elaborately desciribed as the form of fever then most generally prevail- 
ing, a combination of intermittent fever with the endemic typhus of 
^ i : r : J- typhoid fever.) He has subdivided the resulting hybrid 
: iwo chief classes: 1. Typhus inttnnittens subintrans, which 

he defined as a combination of typhus and intermittent fever, with a 
predominance of the typhus element 2. Ftbris intermittens typhosa, 
which he defined as a siTnilar combination, with a predominance of in- 
termittent fever. I would refer you to his elaborate treatise for many 
suggestive details. 

Xaumann ^ has quoted, with approval the views of Burserius and 
Schmidt, and mentions corroborative observations by several other 
writers, to which I might add many more did the scope of this dis- 
course permit 

Becurring to the American experiences, I would recall to your mem- 
ory the fact that the existence of the hybrids under consideration did 
not escape the practical eye of Drake : - "When remittent fever terminates 
fatally in one or two weeks.' he observes, ** a certain amount of subsul- 
tus, a dryness of the tongue, and intestinal hsemorrhage, are sometimes 
present although no typhous fever may be prevailing in that locality, 
and this brings us to inquire, not into the distinctive peculiarities of 
these two forms of fever, but into their combination, into the hybrid or 

• SAf^'AGES. 2t'»JoL}g. Mfzk^. Amsterdam, I j-io. Vol. I, p. 

f J. Baft. Bt-HSEXics. iKstitmi. Med. Vol.1. Milan, 1781. I := :r ~ H : :kcr i Edition, Leipsic , 
iS2!6, Vol. I, p. >12. 

Hekmaxx Schmidt. Uher das Emn^msckt Sammurfieier. Paderborn and Ainsbcrg, iS^a. 
\ O/. cit. Bd. Ill, abth. 11, S. ^35. 



33 



mongrel diathesis which results fi'om the joint impress, in ever-Tarying 
proportions, of the causes which produce true tyj^hous and true remit- 
tent fevers. " * For these hybrid forms he proposes the designation, " Re- 
mitto-typhous or secondary ty^^hous fever." I do not recollect,'" he says, 
" to have seen a case of fever well-mai'ked as typhous in the early stages 
terminate as an inteiniittent, nor a decided intermittent degenerate into 
a tyi^hous. The union is between remittent and typhous." And this 
certainly is the most common combination : but the combination vrith in- 
temiittent does also occiu', though less frequently, and both the possi- 
bilities which Drake tells us he never observed were seen often enough 
dm*ing the civil war. 

The same combination of remittent and typhoid fever which was ob- 
served by Drake has also been described by the late Professor Dickson 
of this city. Dickson continually emphasized the doctrine of the fre- 
quent blending of those febrile types which are connate in cause and 
analogous in symptoms." He tells us that "it is a matter of familiar 
remark, that in long-protracted cases of the ordinary remittent of mala- 
rious regions, there is a domination of the palpable conti'ast or alterna- 
tion of the period of febrile exacerbation and unison— a tendency in the 
former to continuousness. the latter being less an alleviation of the 
symptoms — and the several symptoms themselves approaching more 
and more in appearance those which belong to simple continued fever, 
nervous fever, or tyi^hoid fever. In common professional language, such 
cases 'take on the typhoid chai'acter.'" "On examination, typhoid 
lesions vrill sometimes be found in the body dead of bilious remittents. 
The mucous membrane of the stomach and intestines is highly injected 
in severe and short attacks. In more protracted cases, follicular ulcem- 
tion may be found throughout the whole extent of the bowel, "t 

Similar opinions were long entertained by my revered precei^tor. Dr. 
George B. Wood. He has told you that remittent fever is sometimes 
of a low, adynamic or typhous character fi'om the commencement. This 
may be the result of a previous exposure to causes calculated to dejDress 
the vital powers and to deprave the blood ; but it probably most fre- 
quently arises from the co-operation of a typhoid epidemic influence with 
miasmata." He did not beheve that the chai*acteristic lesions of tyj^hoid 
fever ever occur in pure remittents, as some have reported, and explained 
their observations by the remark that " there is reason to beheve that 
enteric fever has sometimes been mistaken for bihous or remittent fever. 



* Drake. Op. cii, 2d Series, p. 556. 

t S.^MfEL Henry Dickson. Elcvients of Medicine Philadelphia, 1S55, p. 196. Sec also his Essay 

On the BIc7tding and Conversion of Types in Freer. Tr-ir..-. :f t'^.'. Am-.r. M'..\ A-?. :., V-;. 

V, (1S52,) p. 127. 



34 



and lesions belonging to tlie former been placed to the account of the 
latter ; and not imfreqnently, in all probability, the two diseases are in 
greater or less degree mingled together."* 

Now, under the conditions which existed in the camps of our armies 
diu'ing the late civil war, these hybrid combinations, which had already 
attracted the attention of such men as Drake, Dickson, and Wood, in 
civil hfe, made theii' appearance, as might have been predicted, on a 
great scale, and produced, as I have already shown, a formidable mor- 
tality. It was for these hybrid forms that I proposed the term typho- 
malarial fever. I never meant this term to represent a specific type of 
fever, but intended it to designate all the many-faced brood of hybrid 
forms resulting from the combined influence of the causes of malarial 
fevers and of enteric fever. The term corresponds essentially to the " Pro- 
portionata " of Burserius. It includes both the " Typhus intermittens 
subin trans"' and the "Febris intermittens typhosa," of Hermann Schmidt, 
and the Eemitto-ty^^hous " of Drake. These are merely varieties of the 
gi'oup of hybrids, all of which I intended to embrace. I pointed out, 
in my book on Camp Diseases, that this whole gToup might be conve- 
niently divided, for the x^urpose of study, into — 1. Fevers in which the 
malarial element, without being the only pathological condition present, 
is the predominant one ; and, 2. Fevers in which the typhoid element 
is evidently predominant, although the others are a-lso present in a more or 
less distinct manner. To these I felt compelled to add a third group, 
namely, Fevers of either of the first two varieties, in which from the 
fii'st, or at some time during the progress of the affection, the scorbutic 
element becomes predominant." To this general grouping of the cases, 
with all the hght of subsequent experience, I must still substantially 
adhere. 

In the group of cases in which the malarial phenomena predominated, 
the disease began as a simple intermittent or remittent fever, of quoti- 
dian, tertian, or quartan type, the most frequent form being a simple or 
double tertian ; but after a week or ten days the fever assumed a more 
or less completely continued type, with many of the phenomena char- 
acteristic of typhoid fever, such as diarrhcea, abdominal tenderness, 
meteorisin, muttering delu'ium, subsultus tendinum, dry, brown tongue, 
and the like. But even when the typhoid phenomena were most pro- 
nounced some of the most characteristic of them were often wanting. 
Thus, sometimes there was no diarrhoea at all, but constipation instead. 
The characteristic tache rouge, or rose colored eruption, was generally 
entirely absent ; gastric disturbance, hepatic tenderness, and an icteroid 



* Wood. Op. cit. Vol. I, pp. 307 and 309. 



35 



hue of the countenance were mncli more generally present than in 
simple typhoid fever. 

Now, a large proportion of these cases terminated favorably, espe- 
cially, as I think, because quinine was so freely used in their treatment ; 
the occuiTence of ordinary paroxysms of ague was a frequent accident 
during the convalescence. And, just because of the frequency with 
which they recovered, I suppose, the number of autopsies in cases of 
this kind which I have been able to collect is much less than in 
cases of the second gi'oup, of which I shall presently speak. Still, I 
have collected a number of autopsies of cases of this kind, in which 
dian'hcea had been present dui'ing the fever, and in which, after it had 
assiuned a continuous type, it had strikingly resembled typhoid fever, 
but in which dissection showed no other lesion in the alimentaiw canal 
than a smart intestinal catarrh. Patches of inflammation, scattered 
irregularly thi'oughout both small and large intestines, and enlargement 
of the closed glands, often associated with pigment deposits, were the 
characteristic lesions. The sohtary glands of the small intestine ap- 
peared as little projecting tumors the size of pinheads, which often had 
constricted necks, so that they resembled tiny polypi. The agminated 
glands of Peyer, shghtly prominent, were often the seat of pigment 
deposit, which gave them the so-called shaven-beard appearance. Some- 
times the villi of the small intestines were hypertrophied ; sometimes 
they had pigment deposits at their apices. In the large intestine the 
slightly swollen solitary glands were often the seat of pigment de- 
posits, seated either in the glands alone, or sometimes also in the 
surrounding mucosa, in which case the central dot of pigment was sui'- 
rounded by a Httle pigmentary ring. AYhen the fever had supeiwened, 
as often happened, upon a chi'onic flux, or where dysentery had been 
developed dm*ing the course of the fever, or of the convalescence, and 
had been the immediate cause of death, the characteristic folhcular 
ulcerations of the colon or the phenomena of the diphtheritic process 
complicated the pictm-e Great enlargement of the spleen and conges- 
tion of the hver. with or -^"ithout fatty degeneration, were frequent con- 
comitants. The condition of the intestinal canal in these cases closely 
resembled that which has been emphasized by Pioderer and Wagler, 
and by Dickson. Between the simple inflammatory enlargement of the 
closed glands, which I have pictiu'ed, and the more luxmiant process 
which occiu-s in ordinary typhoid fever, and which most pathologists be- 
Keve to be specific, every possible transition existed. I, for one, confess 
myself unable to draw a line between the two conditions. Anatomically, 
they appear to jDass into each other by insensible gi'adations. The es- 
sential element of both is the accumulation of a swai-m of migi-ated white 



36 



corpuscles in the closed glands, in tlie surrounding lympli passages, 
and the adjacent connective tissue, associated, doubtless, as we must 
infer from the study of other inflamed tissues, with multiplication of the 
lymph cells of the parenchyma of the closed glands by division, though 
it is difficult, if not quite impossible, to demonstrate this latter phenom- 
enon in the present case. The sloughing and ulceration of the so-called 
tyi:)hous process is, I think, sufficiently well explained by the intensity 
of the process and the nutritive disturbances which thence result, with- 
out conjuring up in our imaginations an undemonstrated specific some- 
thing to account for it. 

The group of cases in which the tj^Dhoid phenomena predominated 
more closely resembled ordinary typhoid fever. They began more like 
it ; they ran their course like it ; like it, they refused to be cut short 
by quinine ; after death they presented the characteristic lesions of 
the patches of Peyer, But even these cases presented, also, many phe- 
nomena which did not belong to ordinary typhoid fever. First of all, I 
must emphasize the manifestation of an unwonted tendency to perio- 
dicity. This was not merely an exaggeration of the daily exacerbation 
and remission, which we all know as a part of the history of the early 
stages of typhoid fever. The exacerbations assumed with great fre- 
quency a tertian or double tertian type, which has no parallel in the 
ordinary typhoid history. With this tendency to periodicity, the gas- 
tric and hepatic disturbances common in remittent fever were often 
associated in the early stages, and ordinary ague paroxysms often 
occiUTed in the convalescence. The autopsies in these cases disclosed 
the ordinary lesions of typhoid fever. During my earlier studies I 
believed that I had observed certain peculiarities in the character of 
the ulcers in these cases, by which they might be distinguished from 
the lesions of simple typhoid.* A larger experience, especially the 
examination of a large number of specimens received by the Medical 
Section of the Army Medical Museum, has convinced me that this 
opinion was premature. I renounce it as erroneous. There is really 
nothing in the lesions of Peyer's glands, in these cases, to distinguish 
them fr'om ordinary cases of typhoid fever ; and it was just these 
lesions, so well known to you all that I need not pause to describe 
them, which were observed in the vast majority of those fatal cases of 
fever occurring during the late war in which autopsies have been 
recorded or specimens preserved. As for the other lesions observed in 
these cases, tumefaction of the spleen, far beyond the degree ordinarily 
ol)sei'ved in typhoid fever, was common enough, and the pigment de- 



* Camp Diseases, p. 102. 



37 



posits in various tissues and organs, which are so frequent in malarial 
diseases, were very often encountered. Moreover, the colon lesions 
characteristic of chronic fluxes or of acute diphtheritic dysentery were 
frequently associated, as is well shown by numerous specimens in our 
Museum. 

I will not for a moment, however, countenance the sophism that, be- 
cause the lesions of ordinary typhoid fever were those most frequently 
encountered during the war in fatal cases of fever, uncomplicated 
typhoid fever was the prevailing febrile form. On the contrary, as I 
understand it. though this was the lesion in the majority of fatal cases, 
the 'slighter lesions described in connection with the first group were 
those which most probably existed in the majority of the cases which 
recovered. Nor will I admit the fallacy that, even in those fatal cases 
in which the tyi^hoid lesion was most marked, the patients are thereby 
proved to have died of simple typhoid fever. I vnll not emphasize the 
big spleens, pigmentary deposits, or other anatomical evidences of 
malarial comphcation. I will even admit the uncertain diagnostic value 
of all these phenomena in the present state of oui* knowledge. But I 
cannot ignore the facts of clinical observation. I cannot but see in the 
periodicity and other cHnical evidences of malarial complication to which 
I have briefly alluded, proof of the action of an additional morbid agency, 
to which I doubt not we must look for one reason of the great mortality 
of the fever cases in our armies. 

It often happened that, in fevers belonging to either of the classes I 
have just described, scorbutic phenomena complicated the picture, and 
sometimes even took a commanding place in determining the coiu'se 
and issue of the disease. I have af&rmed. and shall elsewhere bring 
forward satisfactory evidence in proof of the assertion, that a mild but 
distinctly recognizable scorbutic taint was wide-spread among our 
soldiers. It manifested itself as a peculiar an?emia. accompanied by 
muddy complexion, large, smooth, flabby tongue, and by nem'algic or 
pseudo-rheumatic pains in various parts of the body, especially in the 
back. As a rule, it was only after this scorbutic anaemia had existed 
for some time, either alone or variously complicated with spnptoms 
. due to malarial poisoning, that the characteristic scorbutic conditions 
of the gums, the scorbutic mdiu*ations about the joints of the lower 
extremities, and the well-known scorbutic purj^ura made their appearance. 
These easily-recognizable symptoms of fully-developed scurvy were but 
moderately frequent. The preliminaiy anaemia, however, was common 
enough, though often overlooked or misimderstood. 

Now, when either of the forms of tyi^ho-malarial fever, which I have 
desciibed, occm-red in individuals suffeiing under the scorbutic taint, the 



38 



symptoms were modified to a degree corresponding to the intensity of 
the scorbutic condition. The effect of the comphcation was to increase 
the tendency to mental and bodily prostration during the disease, to 
tardy convalescence subsequently, and to increase the frequency of pe- 
techial and purpuric eruptions, and of hfemorrhages fi-om the nose and 
bowels. Sometimes the characteristic scorbutic condition of the mouth 
was developed dm'ing the progTess of the fever, when it had not previ- 
ously made its appearance. When the characteristic typhoid process 
was developed in individuals laboring under a marked scorbutic taint, 
the symptoms closely resembled those of spotted typhus. Fatal haemor- 
rhages fi'om the bowels were common in such cases, and on the dissec- 
tion, the lower patches of Peyer were found converted into dark-red or 
black pultaceous sloughs of considerable size and thickness. I suppose 
the scorbutic condition to have modilied the typhoid ulceration in such 
cases, just as we often see it modify the condition of superficial ulcers 
or of gunshot wounds. 

The outlines of the chief phenomena of typho-malarial fever which I 
have thus endeavored to present to you to-day are necessarity incomplete, 
for it is. of com'se. impossible to go into the details of so large a sub- 
ject in an address like this. I hope to be able to fill up these outlines 
in a satisfactory manner in the second volume of the Medical History 
of the War. 

And this brings me. at length, to answer the cpiestion — Is typho-ma- 
larial fever a special type of fever ? — and I reply, unhesitatingly, that it 
is not. I, at least, am free from the blame of that error, if any one has 
fallen into it. Li my first published account of ty}3ho-malarial fever, I 
expressly denied that it could be regarded as a new disease. "Much 
rather,"" I said. should it be considered simply as a new hybrid of old 
and well-known pathological conditions, in which the exact train of 
symptoms is as variable as the degree of preponderance attained by 
each of the several concurring elements."'* And this is the view which 
I advocate to-day. The essential point which I desire most to impress 
upon you is the recognition of the group of hybrids between typhoid fe- 
ver and the malarial fevers. The scorbutic complication was a mere acci- 
dent of the war : its existence is by no means Essential to the idea of 
ty]^)ho-malarial fever, but in dealing with the typho-malarial fever of the 
war I could not omit it from the pictm'e. 

It was. and still is, my belief that the mixed forms of fever which I 
have thus sketched constituted the great majority of the continued 
fevers of our aimy during the civil war. I still, however, adhere to the 

* op. cit., p. III. 



39 



opinion which I expressed in Cu'ciilar No. 15 of 1803. and in Circular 
No. 6 of 1865, that simple typhoid fever and simple remittent fever did 
also occiu", though the statistics fail to show to what extent ; and I still 
adhere, also, to the view then expressed, that a large portion of the cases 
actually reported during the war as typhoid and remittent fevers are, 
to a gTeat extent, to be regarded simply as those in which the ty[)hoid 
or the paroxysmal phenomena predominated."' 

It would follow, from the views I have advanced, that typho-malarial 
fever ought to be encountered also in civil life, particularly in our Southern 
States ; not, indeed, to the same extent that it existed diuing the war, 
when hundi'eds of thousands of soldiers, born and bred in the Northern 
States, campaigned in the malaiial valleys of the South, but to an ex- 
tent which desei'ves thoughtful recognition. And this. I must believe, 
fi'om my own observations, and fi'om facts communicated by professional 
friends in various parts of the South, is actually the case. 

Since the close of the civil war my doctrine of typho-malarial fever 
has been accepted with approval in many quarters, and the term has 
been extensively used. Dr. Meredith Clymer* has adopted it as a 
synonym of American Camp fever " in his edition of Aitken's Science 
and Practice of Medicine. Dr. George B. Wood,t though unwilling to 
adopt the name, has fully recognized the great prevalence during the 
civil war of ''this mixtirre of the tw^o fevers." In the sixth edition of 
his work on Practice of Medicine, published in 1866, he remarks : 
" Since the last edition was published this complex affection has been 
much more prevalent than before, probably because great nmnbers of 
young men engaged in the armies at an age when the predisposition to 
enteric fever is strongest, have been in an unusual degr-ee exposed to the 
joint action of the causes of the two fevers ; to that of enteric fever, in 
the almost unavoidable filth attendant upon great encampments, and 
to that of bihous remittent or intermittent in the low gr'oimds from 
which miasmatic efSuvia are so abundantly extracted in om- Middle and 
Southern States in the latter part of summer and in autumn. ' 

Dr. Austin Flint, i whose former experience in the South makes me 
regard his opinion in this matter as particularly valuable, in his Treatise 
on the Practice of Medicine, has adopted the term typho-malarial fever 
as a convenient designation to represent the hybrids which had been 
indicated by Drake and Dickson, and which Flint hiujself tells us he 

* Wm. Aitken. The Science and Practice of Medicine, with additions by Mekedith Clymek. 
Philadelphia* 1S72, Vol. i, p. 607. 
\0p. cit.. Vol. I, p. 377. 

J Austin Flint. A Treatise on the Priticiples and Practice 0/ Medicine. Philadelphia, 1S66, p. 
749 ; also, Fourth Edit. Philadelphia, 1S73, p. 934. 



40 



has recognized in bis own lectures to medical classes for twenty -five 
years. His article on simple remittent and typlio-nialarial fever is an 
admirable one, to wbicb I refer yon witb pleasure. 

Witb tbis intelligent corroboration and support of my vicAvs on typbo- 
malarial fever, tbere lias been, I must admit, some indiscriminate use 
of tbe term, wbicb is well calculated to bring it into discredit. I bave 
myself known it to be erroneously applied to simple typboid fevers, in 
tbe clinical bistory of wbicb I at least could see notbing to indicate a 
malarial complication, and to simple remittents in wbicb I could per- 
ceive no typboid symptoms. I tbink I bave observed, also, a tendency 
in certain quarters to bestow^ tbe term upon almost any obscure febrile 
affection wbicb offered diagnostic difficulty. May I not bope tbat tbe 
dissemination of tbis addi'ess may serve to diminish abuses of tbis kind 
hereafter "? 

But although wddely accepted, my views witb regard to typbo-malarial 
fever bave not escaped criticism. Dr. Roberts Bartbolow,* formerly an 
Assistant Surgeon of tbe Army, and now a successful practitioner in 
Cincinnati, has attacked them witb a good deal of acrimony in an ar- 
ticle on tbe Camp Fevers of tbe Civil War, w4iicb be contributed to tbe 
Medical Volume of tbe Memoirs of the United States Sanitary Commis- 
sion, Led away by' tbe energy of bis attack, be goes so far as to 
affirm boldly " a typh element did not in my experience exhibit itself as 
a modifying condition in remittent fever." He declares the camp fevers 
of tbe army to bave been remittent, simple continued, typboid, and 
typhus, and affirms that " these several forms of fever preserved as dis- 
tinct clinical features in tbe army as tbe same forms of disease in civil 
life." To give force to his criticism, be even goes to tbe extent of 
misrepresenting my views, and says : " There were, therefore, according 
to Woodward, really no cases wholly typhoid, or wholly remittent, in 
tbe army " — although I bad distinctly affirmed tbe occurrence of such 
cases in all my publications on tbe subject. I will not pause in this 
place to answer these criticisms of Dr. Bartbolow in detail. I would 
merely remark that, although be makes typhus one of the forms of 
camp fever, be himself admits that be has no knowledge of it from 
personal o]:)servation. And though he is so ready to deny that the 
typli element, as be calls it, can complicate malarial fevers, be is com- 
pelled to concede tbat tbe malarial influence can complicate typboid 
fever. Tbis be has exj^licitly affirmed to be a common occurrence in 
civil life, in another article contributed to tbe same volume of tbe Me- 
moirs of tbe Sanitary Commission. His language is : "I bave already 



* RoiiEKTS Baktholovv. Cavip Fevers, being chap. 2 of the Medical Volicine of the'_3femoirs of the 
U. S. Sanitary Commission. New York, 1867, p. 193, et seq. 



41 



adverted to the fact that, as populations increase in malarious districts, 
typhoid supplants the intermittent and remittent fevers. Diuiug the 
transition period a mixed fever prevails : it is a typhoid fever with a 
malarial complication.' " He admits, therefore, the combination of 
malarial and typhoid fevers, but holds that the typhoid element is al- 
ways dominant. Against this. I maintain that sometimes the one and 
sometunes the other of the two elements predominates, and I must be- 
lieve that the facts are on my side. I may add that the distinguished 
editor of the volume of Memoirs in question. Dr. Austin Fhnt. felt 
himself called upon to append to Dr. Bartholow's essay the following 
remark : The general favor with which the term typho-malarial has 
been received, and the readiness with which it has come into vogue, 
show that it expresses a pathological doctrine consistent with clinical 
experience."'! 

In his hasty criticism. Bartholow falls into another error — so mis 
chievous. that 'I cannot permit it to go unchallenged. He denies the 
frequency of a scorbutic taint among oiu' soldiers during the .ci^-il war. 
and thinks that even the cases reported as actual scurvy include many 
of " ordinary stomatitis. " He says: In a pretty extended course of 
observation. I did not meet during the war a single well-marked case of 
scorbutus."! A general belief that Bartholow's opinions as to this 
matter are correct would be a serious obstacle to any attempt to improve 
the alimentation of our soldiers in any futiu'e war. In fact, however, 
this opinion is so far wide of the truth, that I can only understand it as 
an illustration of the extent to which one may be led astray l)y the 
eagerness of controversy. It is not necessary to leave the volume in 
which Bartholow's paper is printed to find evidence to contradict him. 
You will find such evidence in the paper by Dr. Sanford B. Hunt.§ which 
constitutes the thii'd chapter of the volimie ; and in the fii'st chapter of 
the volume, by Dr. Bartholow himself.|| he makes a series of statements 
which fully justify my views. Thus, he affii'ms that the amount of 
aliment fm-nished to the various armies was too often determined by 
the transportation available for bringing it forward, and by the so-called 
mihtary necessity;'" and that "the armies operating in the interior 
region were more affected by deficiencies in commissariat sujDphes than 
those on the Atlantic coast, " of which fact he gives several stiiking 
examples. He explicitly states that "the diet was not sufficiently 
varied. " "Anti-scorbutics came to be furnished after the fii'st year of 
the war, but the chief antiscorbutic — the potato — was practically una- 
vailable, from the difiiculty of transporting and preserving it."' 

Is it wonderful that, in this connection, Dr. Biu'tholow, adopting the 



* op. cit., p. 126. t op. cit., p. 214. + Op. cit., p. 196. lOp. cit., p. 64. Op. cit., pp. 16-19. 



42 



very term lie criticises when used by me, should have felt compelled to 
Avrite : "A scorbutic taint was to be observed in troops who had served 
in the South for a considerable period ;" and, further on, that an 
impoverished state of the blood, due to defective alimentation, undoubt- 
edly existed to a large extent. It exhibited itself in various forms, but 
especially in increasing the fatality of diseases and in impressing an 
adj^namic character on those of mild and tractable forms." Still fur- 
ther : " The camp fever of the army was essentially typhoid. It was 
modified by various accidental and specific causes. We have just 
alluded to one of the specific modifying causes — malaria. The most 
important of the others was scorbutus." 

It would occupy too much time for me to attempt to bring forward 
even a small part of the evidence on which my belief of the wide-spread 
existence of a scorbutic taint among our troops during the late war 
rests. My own observations and opinions have been corroborated by 
those of numerous capable medical ofiicers. As for actual pronounced 
scurvy, so. fully developed that it could be recognized by the average 
regimental surgeon, 30,714 such cases, not of the scorbutic taint, but of 
" SCURVY," were officially reported among the white troops during the 
war, and 16,217 among the colored troops.* 

The other critic to whom I desire to refer is Dr. Jerome Cochran of 
Mobile, whose objections I find in the Transactions of the Medical Asso- 
ciation of the State of Alabama for 1875.t This gentleman's service as 
a Sm'geon in the Confederate Army inclines me to regard his somewhat 
grotesquely presented criticism with a respect I could not have felt had 
it proceeded from a less reputable source. Singularly enough his ob- 
jections precisely contradict the objections of Bartholow ; so that I 
might readily call upon either gentleman as a useful witness to contra- 
dict the asseverations of the other. Bartholow will see nothing in 
the continued fevers of the war but the typhoid element ; Cochran will 
see nothing in the fevers around Mobile but the malarial element. 

*'J'hc ralio of these cases lu strength greatly increased during tlic latter jKirt of the war, and attained 
forniidahle proportions anioni; the troops sent to Texas during the year following the war. 'J'lie follow- 
ing ratios arc computed from tlie tahles iniblished in the first volume of the Medical History of the War : 
Ratio uf Case a of Scurvy per i ,ooo of mean strength. 
will l ie i Kodrs. 

Year ending June 30, i8''j2 4-7 

" iHr,, 12.6 



1865.. 
1866., 



Year ending June 30, 1864 66.5 

" " 1865 65.0 

" " 1866 141-6 

tJi'.KOMK CoCHKAN. Notc B. Typko-mahir ial lu-r,r. I rans. of the Med. Association of the Stale of 

Alabama, 28lh Session, 1875. Montgomery, Ala., 1075, p. jjy. 



43 



"During the last six months," he writes, "several cases of protracted 
fever, primarily of malarial origin, but assuming in their course certain 
typhoid symptoms, have been related to the Society under the name of 
typlio -malarial fever." He objects to this term and the theory which it 
implies. He thinks the fevers in question are purely malarial. " The ma- 
larial mother is easily found, the fruitful mother of many children, but 
for the typhoid father I have looked in vain through all the streets and 
alleys, in all the wards and suburbs of the city;" and again : "lean 
only continue to say that if we have typhoid fever here, I have never 
seen it." 

Now, the very same volume in which Dr. Cochran publishes this, con- 
tains a tabular statement of the deaths in Mobile during the year 1874. 
Among these I find 3 from intermittent fever, 12 from remittent fever, 
7 from congestive fever, 1 from typlio -malarial fever, 6 from yellow 
fever, 1 from hsemorrhagic-malarial fever, and 5 from typhoid fever.* 
Dr. Cochran himself tells us in the course of his remarks that his an- 
tagonists among the Mobile physicians declare the existence in that 
town of "a continued fever with diarrhoea, dry tongue, frequent deli- 
rium, a rose rash, running a persistent course of three weeks or more, 
and defying all treatment to arrest its progress ;" but he will not admit 
that this fever is typhoid. He does not bring forward any dissections 
in j)roof of his views ; indeed, he does not appear to have made a single 
autopsy in any of the cases in dispute. He bases his opinion entirely 
on a priori considerations deduced from his belief in the incompatibility 
of the idiopathic fevers. He proclaims that " there can be no doubt 
whatever of the truth of John Hunter's general doctrine, that no two of 
them can exist in the same part of the body at the same time." I can 
only express my belief that if Dr. Cochran had spent a part of the time 
which he has employed in criticizing my views, in making, with his 
fellow-practitioners, some autopsies on the cases of fever, which he tells 
us they persist in calling typho-malarial and typhoid, he would have 
arrived at results quite at variance with the opinions he has expressed. 

And now, one word before I close, as to the question of nomenclature. 
Is it convenient to bestow a single term, as I have done, upon the whole 
brood of hybrid forms resulting from the simultaneous action of malaria 
and of the causes of typhoid fever ; or, is it best to use several designa- 
tions according as the one or the other of the two elements predomi- 
nates"? We might give the cases in which the typhoid element pre- 
dominates the name miasmatic-typhoid fever, suggested by Levick,t 

*Oj>.cit., p. 314- 

t 0/>. cit. supra ; also a lecture by the same author, Miasviatic Typhoid Fever. Med. and Surg. Re- 
porter, June 21, 1862, p. 283. 



44 



aud call those in which the malarial element predominates typhoid- 
miasmatic fever. Such a double nomenclature we have already seen 
was suggested by Hermann Schmidt. We might go still further, and 
apply special names, in accordance as the malarial element showed itself, 
by giving to the early stages of the case an intermittent or remittent 
type. I do not think this is at all necessary, I think a single term 
which shall include all the hybrids quite sufficient ; but I shall not 
quarrel with, any one who wishes to make further subdivisions. 

If we agree to represent all these hybrid forms by a single appel- 
lation, is the designation Typho-malarial the best for the purpose ? 
Would it be an improvement to adopt the term entero-miasmatic," 
suggested as a substitute by Dr. George B. Wood f * I confess to a 
preference for the term I have suggested. It is easy enough to pro- 
nounce, and seems to me to express its meaniiDg very well ; but I attach 
far less importance to the employment of the name which I have sug- 
gested than I do to the recognition of the compound forms of fever 
which I intended to represent by it. The name is, after all, a mere 
matter of choice. But if I have rightly presented the subject, a just 
appreciation of the hybrid forms which I have urged on your atten- 
tion to-day is a matter of grave practical importance. Not merely as a 
question of Military Medicine, though most important in that conuec- 
tioD, for I take it that whenever again hereafter an army recruited in a 
comparatively non-malarial region shall campaign on a malarial soil 
these hybrid forms will appear once more in epidemic proportions ; but 
meanwhile, I suppose, in sporadic or endemic-wise, we shall continue 
to have these cases to deal with in civil practice in all the miasmatic 
regions of our Middle and Southern States, and their right compre- 
hension is, therefore, a question of serious moment to every Ameri- 
can physician engaged in practice in such localities. 



* Oj>. cit.. Vol. 1. p. 377. 





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